Biomedical subjects
Publications and source records attributed to B Launois.
The authors report a case of neuroendocrine carcinoma of the lower third of the esophagus. Immunohistochemical study revealed that most tumor cells expressed neuron specific enolase, chromogranin A, carcinoembryonic antigen and glucagon. They insist on the usefulness of this study on biopsies in order to guide therapeutic decision.
BACKGROUND: Observations from 75 patients undergoing resection of the liver during a recent period have been analyzed with respect to the use of perioperative blood transfusions and operative outcome. METHODS: Twenty-six patients were operated on for benign disease and 49 patients for malignant disease. Twenty-one patients underwent a right or left hepatectomy, 49 patients underwent removal of one or more anatomic segments of the liver, and five patients underwent wedge resection of a lesion in the liver. There was one postoperative death. RESULTS: The median blood loss was 0 units (range, 0 to 15 units). Sixty-three percent of the patients underwent operation without the need for a blood transfusion. The median postoperative stay was 10 days (range, 4 to 88 days). In the group of patients who did not undergo a blood transfusion the median postoperative stay was 9 days (range, 4 to 28 days), and in the patients who had a blood transfusion it was 14 days (range, 6 to 84 days) (p less than 0.0003). CONCLUSIONS: The performance of major liver resection without a blood transfusion is a realistic objective.
This work reports a retrospective multicenter study of the treatment and prognosis of 746 patients with gall bladder cancers and 684 patients with extrahepatic biliary duct cancers. Gallbladder cancers: Adenocarcinoma was encountered in 92.6% of cases, 107 were limited to the gallbladder. Removal was possible in 27% of the patients. Overall operative mortality was 21%. Overall survival at one year was 14%. The projected five-year survival for cancers limited to the gall bladder treated by simple cholecystectomy was 93% for noninvasive, "in situ" cancers. The survival was 18% with mucosal involvement, and 10% with extension to the gall bladder wall. Extrahepatic biliary duct cancers: Adenocarcinoma was encountered in 99.7% of assess; 40 were limited exclusively to the biliary ducts. 384 involved the upper 1/3 segment of the biliary duct, 86 the middle 1/3, and 121 for the lower 1/3. Cancers involving two or more of these segments were encountered in 93 cases. Removal of the cancer from these four locations was possible in respectively 30%, 50%, 50% and 7% of cases. Overall operative mortality was 27.7% and after removal: 13.5% for the upper biliary duct segment, 18.1% for the middle 1/3, and 20% for the lower 1/3. The mortality was 25% for cancer that involved two or more of these segments. Analysis related to age demonstrated a postoperative mortality of 16% in patients less than 70 years of age and 59.1% after 70 years. The five-year survival after surgery was projected to be 12% for cancers of the upper 1/3 segment, 15% in middle and 30% in the lower 1/3.(ABSTRACT TRUNCATED AT 250 WORDS)
Therapy of variceal bleeding is currently based on endoscopic sclerotherapy. However, the treatment of bleeding recurrences after sclerotherapy has not yet been established, but consists of the choice between continuation of sclerotherapy or a surgical procedure. We report herein the results of portocaval shunt performed in 26 cirrhotic patients among the 175 cirrhotic patients (15%) admitted between 1985 and 1990 to our Intensive Care Unit for variceal bleeding. These 26 patients were operated because of failure of sclerotherapy as defined by haemostasis failure (n = 1), the persistence of unchanged oesophageal varices after six sessions of sclerotherapy (n = 1), and the occurrence of at least one severe episode of rebleeding (n = 24). Emergency and elective portocaval shunts were performed in 12 and 14 cases respectively. The time delay between admission and surgical procedure was equal to 21 +/- 8 hours and 12 +/- 4 days in the two groups respectively. The operative mortality (30 days) was equal to 23% and was observed in emergency shunts only. Actuarial survival rates were significantly different between the two groups (p < 0.01). Predictive factors of mortality as assessed by univariate analysis were the emergency nature of the procedure, serum aminotransferases and urea levels at the time of the index bleeding, and the number of bleeding episodes related to portal hypertension before the index bleeding. The prognosis at one year was not influenced by the number of bleeding recurrences between the index bleeding and the bleeding episode justifying the shunt.(ABSTRACT TRUNCATED AT 250 WORDS)
Glisson's capsule extends into the liver as sheaths around the hepatic ducts, hepatic arteries and portal tributaries. Within the hepatic substance, these structures need not be dissected individually, but the sheath can be ligated "en masse." These sheaths can be approached either anteriorly (after division of the main fissure or right fissure or umbilical fissure) or posteriorly from behind the porta hepatis. We recently used these approaches in 70 patients during a 27 month period. The median blood loss was zero units and there was one postoperative death. We believe the technique adds precision and safety to surgical treatment of the liver.
We have described herein an anterior and posterior perihilar intrahepatic approach to the hepatic sheaths of the segments of the liver. This approach allows early delineation of the anatomy of the liver and we believe it is a useful addition to the techniques available for operating on the liver.
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Five hundred fifty-two cases of primary carcinoma of the extrahepatic bile ducts (gallbladder and periampullary tumors excluded) collected from 55 surgical centers were reviewed retrospectively. Three hundred seven patients (56%) had upper-third lesions (proximal carcinoma), whereas 71 (13%) and 101 (18%), respectively, had middle-third and lower-third bile duct carcinomas. The remaining patients had diffuse lesions. Resectability rates were 32% for upper-third localization compared to 47% and 51% for middle-third and lower-third localization, respectively. The operative mortality rate for proximal carcinomas was significantly lower with resection (16%) compared with palliative surgery (31%) (p less than 0.05). Overall 1-year survival (operative deaths excluded) was 68% after tumor resection compared to 31% after palliative surgery (p less than 0.001). Long-term results after surgical resection correlated with local and regional extension of the disease. The results of this study show that resection of extrahepatic bile duct carcinomas, particularly in an upper-third localization, often is associated with worthwhile long-term survival.
Normal human adult hepatocytes were examined for their ability to synthesize and secrete factor V using primary culture. The culture medium contained both factor V and factor Va as determined by bioassay and activation experiments. Immunoprecipitation of newly synthesized labelled factor V showed the presence of both native factor V (m.w. 330,000) and two fragments of respective molecular weight 300,000 and 265,000. Northern blot analysis revealed the presence of a single 7 kb factor V mRNA in cultured human hepatocytes as in liver biopsies, together with fibrinogen beta and albumin transcripts. Relative levels of factor V, fibrinogen beta and albumin mRNAs differed when the cells cultured, suggesting that expression of the three corresponding genes might in part be independently regulated. Furthermore, addition of glucocorticoids enhanced factor V and fibrinogen beta mRNA levels 1.6- and 5-fold respectively, but did not significantly increase that of albumin. These results provide evidence that human hepatocytes actively participate in the synthesis of plasma factor V and constitute a valuable model to study the common and specific regulations involved in the control of the expression of this gene in human liver.
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We report a case of malignant melanotic melanoma involving the extrahepatic biliary tract in a 34-year-old white woman. The diagnosis was established using conventional light microscopic examination and immunohistochemical stains. The clinical absence of any primary cutaneous or visceral melanoma suggests that the tumor arose primarily from the biliary tract. To our knowledge, only two previous cases of malignant melanoma of the common bile duct have been reported in the literature.
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From April 1978 to 1st October 1990, 19 patients underwent liver transplantation for primary or secondary cancer of the liver. Eleven patients were transplanted for hepatocellular carcinoma secondary to cirrhosis, generally alcoholic (9 cases), hepatitis B (1 case) or secondary to haemochromatosis (1 cas). Three patients developed hepatocellular carcinoma in a normal liver, including one fibrolamellar cancer and three a proximal bile duct cancer. Lastly, two patients received a graft for secondary cancer from a colonic adenocarcinoma and a carcinoid tumour of the right colon. The operative mortality was nil for the transplantations for cancer in a normal liver, but there were 4 deaths out of the 11 cases of cancer secondary to cirrhosis. The actuarial survival of the overall series was 55% at 1 year and 31% at 2 years. The poorest survival was observed for cancers in a normal liver, with the exception of the fibrolamellar cancer in which recurrence was delayed. The longest survival was observed for cancers secondary to cirrhosis. At three years, the results of liver transplantation were equal to those of hepatic resections with a survival of 37%, despite the fact that the transplantation was generally performed for very large tumours.
In liver transplantation, the quality of the immediate postoperative period depends on a perfect surgical technique and, notably, on the quality of the hepatic arterial blood flow. In case of arterial abnormality, the reconstruction resulting from a donor's right hepatic artery is performed either by Gordon's technique or by reimplantation of the patch on splenic artery. An insufficient hepatic arterial blood flow requires the installation of an iliac artery graft between the recipient's aorta and the donor's coeliac patch. The presence of portal thrombosis, parietal defect or portocaval anastomosis requires the use of an interposed iliac vein graft. Direct implantation on the superior mesenteric vein suppresses the need for dissection of a portocaval shunt or resection of the thrombotic vein.
A 30-year-old woman underwent a liver transplantation for metastasis of a carcinoid tumor of the midgut previously resected. Operative manipulation of the liver resulted in arterial hypotension, tachycardia, high pulmonary arterial pressure, oedema of the face and peripheral cyanosis, although the patient was given somatostatin (Modustatine, Clin-Midy) (300 micrograms a hour) prior to the procedure. The improvement of the symptoms was obtained by the increase of somatostatin infusion rate to 750 micrograms a hour associated with dopamine (6 micrograms.kg-1.min-1) and fluid replacement. The diagnosis of carcinoid syndrome is discussed. This unusual observation stresses the difficulty in preventing and/or treating a carcinoid shock. If somatostatin seems to be the treatment of choice of such a syndrome, its role in that case was limited.
The colon or stomach is generally used for extended oesophagoplasty. These pediculated plasties may be complicated by necrosis or stenosis and require total or partial resection at a later stage. We report such an outcome in this case report: failure of left coloplasty, partial failure of right coloplasty and stomach then rendered unusable. The cervico-thoracic oesophagus was reconstructed using a free revascularised small bowel transplant, re-establishing the continuity between the cervical oesophagus and the retrosternal right colon. This case presents several particularities: semi-emergency salvage procedure, use of a saphenous vein graft to revascularise the intestinal artery using the lingual artery as nutrient artery, venous drainage of the transplant via the intrathoracic left brachiocephalic vein, necessity for resection of the left half of the manubrium sterni and the head of the left clavicle.