Biomedical subjects
Publications and source records attributed to C Deschamps.
Surgical treatment for cancer of the esophagus most often involves replacement of the esophagus with a gastric conduit. This gastric tube relies upon the continuity of the gastroepiploic artery for its blood supply. This case report involves a patient whose gastroepiploic artery became thrombosed by a percutaneous endoscopic gastrostomy, rendering his gastric conduit unusable.
Intraoperative radiotherapy (IORT) allows delivery of radiotherapy doses in excess of those typically deliverable with conventional external beam radiotherapy. IORT has potential utility in clinical situations, such as treatment of esophageal and gastric malignancies, in which the radiation tolerance of normal organs limits the dose that can be given with conventional radiotherapy techniques. We reviewed the records of 50 patients who received IORT for locally advanced primary or recurrent gastric or esophageal adenocarcinomas deemed unresectable for cure. IORT was given as a single fraction of electron beam radiotherapy (10-25 Gy) after maximal tumor resection: R0 in 42%, R1 in 46%, and R2 in 12%. Forty-eight patients also received external beam radiotherapy (8-55 Gy), 46 received radiosensitizing chemotherapy, and nine received systemic chemotherapy after radiotherapy. Outcomes were estimated with Kaplan-Meier analysis. Median survival was 1.6 years. Overall survival at 1, 2, and 3 years was 70%, 40%, and 27%. Of 42 patients who died, 37 died from cancer progression and three from multifactorial treatment toxicity. Median survival for patients with recurrent disease versus primary disease was 3.0 years versus 1.3 years (P < 0.05), with a delay of metastatic failure in patients with recurrent tumors (P = 0.06). At 3 years, distant metastatic failure was 79%, local failure was 10%, and regional failure was 15%. IORT for locally advanced primary or recurrent gastric malignancies effectively decreases the risk of local failure. For patients with isolated local recurrences, IORT may be effective salvage therapy. However, more effective systemic therapy is needed as a component of treatment.
Nocardia cyriacigeorgica is a recently characterized species within the genus of Nocardia. We report a brain abscess, following a primary pulmonary colonization, due to this species in a human immunodeficiency virus-infected patient. This case confirms that isolation of Nocardia in sputum is associated with a high risk of disseminated infection in immunocompromised patients.
OBJECTIVES: To assess the use of microbiological examinations, notably serology, in the etiological diagnosis of pulmonary diseases in a department of infectious diseases. METHODS: A retrospective study assessing the habits of microbiological examination prescriptions in pulmonary infections was carried out from 1/05/2000 to 31/10/2001. All patients admitted during this period for pulmonary infection diagnosis and treatment in the infectious diseases and tropical Unit of Saint Antoine Hospital (Paris), were included. The relevance of use of the following diagnostic procedures was assessed: cytobacteriological examination of sputum, specimens obtained on bronchoscopy, hemoculture, serology and search for Legionella urinary antigens. Factors having influenced the co-prescription of these microbiologic examinations were analysed. RESULTS: The survey concerned 179 patients: 7 acute bronchitis, 25 acute exacerbations of chronic bronchitis and 147 community-acquired pneumonia. Microbiological diagnosis was obtained for 34 patients (17.4%), primarily on respiratory specimens. Serology was prescribed in 61 cases with a second serology in 23% (14/61). The principal factor predictive of bacterial serology prescription was the existence of interstitial opacity on chest radiography. Likewise, the search for Legionella urinary antigens was associated with the presence of interstitial opacity on the X-ray and of hyponatremia. However, it was only carried out in 37% of pneumonia with serious clinical presentation (25/67) and was followed by the prescription of combined antibiotics in 70% of the cases (40/57). CONCLUSION: Assessment of the microbiology diagnostic methods of pulmonary infections showed the misuse of serology and insufficient prescription of the search for Legionella urinary antigens, recommended in the case of serious clinical signs.
Although Brucella is responsible for one of the major worldwide zoonosis, our understanding of its pathogenesis remains in its infancy. In this paper, we summarize some of the research in progress in our laboratory that we think could contribute to a better understanding of the Brucella molecular virulence mechanisms and their regulation.
Ceramide participates in signal transduction of IL-1 and TNF, two cytokines likely involved in cartilage degradation in osteoarthritis. We previously showed that ceramide stimulates proteoglycan degradation, mRNA expression of matrix metalloproteinase (MMP)-1, -3, and -13, and pro-MMP-3 production in rabbit cartilage. Since aggrecan, the main cartilage proteoglycan, can be cleaved by metalloproteinases both of MMP and aggrecanase type, the aim of this study was to determine if ceramide stimulates aggrecanase action and, if that is the case, in which measure aggrecanase mediates the degradative effect of ceramide. To this end, antibodies were used against the C terminal aggrecan neoepitopes generated by aggrecanases (NITEGE(373)) and MMPs (DIPEN(341)). Ceramide C(2) at 10(-5) to 10(-4) M dose-dependently increased NITEGE signal, without changing that of DIPEN, in cultured explants of rabbit cartilage. The effects of 10(-4) M C(2) on NITEGE signal and proteoglycan degradation were similarly antagonized by the metalloproteinase inhibitor batimastat, with return to the basal level at 10(-6) M. These results show that, similarly to IL-1 and TNF, ceramide-induced aggrecan degradation is mainly due to aggrecanases. That no increase of MMP activity was detected, despite stimulation of MMP expression, was probably due to lack of proenzyme conversion to mature form, since addition of a MMP activator to C(2)-treated cartilage increased both DIPEN signal and proteoglycan degradation. These findings support the hypothesis that cytokine-induced ceramide could play a mediatory role in situations of increased degradation of cartilage matrix.
PURPOSE OF THE STUDY: Bone grafts or bone substitutes are required to fill bone defects resulting from trauma or surgical resection of tumors. Calcium-phosphate ceramics are synthetic bone substitutes which promote new bone formation by osteoconduction. These ceramics possess osteoconductive properties but have no intrinsic osteoinductive capacity. They are unable to induce new bone formation in extraossesous sites. One solution to develop bone substitutes with osteogenic properties would be to associate biomaterials with osteoprogenitors. MATERIALS AND METHODS: We studied the in vitro osteogenic potential of human bone-marrow cells cultured on macroporous calcium phosphate (CaP) ceramic, examining stromal cell proliferation and differentiation. Osteogenic differentiation was evaluated in terms of alkaline phosphatase activity and immunological characterization of the extracellular fibrillar matrix formed by these cells. The specimens were examined by scanning and transmission electron microscopy. RESULTS: Human bone-marrow cells proliferated on CaP ceramic. The proliferating bone-marrow cells expressed an osteoblastic phenotype as shown by alkaline phosphatase activity and synthesis in ceramic pores of an extracellular matrix composed of fibronectin, osteocalcin and collagen I. In addition, numerous microcrystals of apatite precipitated on the fibrillar matrix, producing a mineralized fibrillar network within the ceramic. CONCLUSION: This study demonstrates that human bone-marrow cells cultured on macroporous CaP ceramic do not lose their osteoblastic phenotype even after 21 days of culture, and that they can induce osteogenesis in a CaP ceramic in vitro. This type of new "hybrid material" appears promising for the future.
Quantitative experimental data showed differences in bone quality and ceramic incorporation between bone-rich and bone-poor implantation sites. Bone in-growth was significantly lower for ceramic implanted at a lumbar intertransverse than a laminar site. Bone-marrow enrichment of the lumbar intertransverse site (regarded as bone-poor) greatly facilitated ceramic osteointegration. The vertebral interbody site, despite theoretical richness in osteogenic precursor cells, might be bone-poor at the time of grafting as compared to the reference iliac crest site. These data have important clinical implications concerning the potential benefit of enriching both bone-poor and bone-rich sites.
BACKGROUND: Surgical resection of isolated hepatic or pulmonary metastases secondary to colorectal cancer has been shown to yield acceptable long-term survival. However, results are inconclusive for surgical resection of both hepatic and pulmonary metastases. METHODS: We reviewed the records of all patients who underwent surgical resection of both hepatic and pulmonary metastases from colorectal cancer between 1980 and 1998. RESULTS: A total of 58 patients underwent resection of both hepatic and pulmonary metastases secondary to colorectal cancer. All patients had local control of their primary cancer before metastasectomy. There were no operative deaths. Morbidity occurred in 12% of patients. Follow-up was complete in all patients, with a median duration of 62 months (range, 6 to 201 months). The 5- and 10-year survivals were 30% and 16%, respectively. A premetastasectomy carcinoembryonic antigen level greater than 5 ng/mL increased the risk of early death (p = 0.029). Neither the number of pulmonary lesions nor the time interval between the primary surgery and the metastasectomy had a significant impact on survival (p = 0.67). At 5 years, 55% of patients were free of disease. Four patients had lymph node involvement at the time of pulmonary resection and all 4 patients died within 22 months of their pulmonary metastasectomy. CONCLUSIONS: Resection of both hepatic and pulmonary metastases secondary to colorectal cancer in highly selected patients is safe and results in long-term survival. Thoracic lymph node involvement and elevated carcinoembryonic antigen levels before pulmonary metastasectomy are associated with reduced survival.
BACKGROUND: To examine the efficacy of the Ivor Lewis esophagogastrectomy for esophageal carcinoma prior to the widespread use of preoperative chemotherapy and irradiation, we reviewed our experience. METHODS: We reexamined the cases of 220 consecutive patients who underwent an Ivor Lewis esophagogastrectomy for esophageal cancer from January 1992 through December 1995. RESULTS: There were 196 men (89.1%) and 24 women. Median age was 65 years (range, 29 to 85 years). The results of pathological study showed adenocarcinoma in 188 patients (85.5%), squamous cell carcinoma in 31 (14.1%), and leiomyosarcoma in 1 patient (0.5%). Postsurgical staging was as follows: stage 0 in 10 patients, stage I in 19, stage IIa in 38, stage IIb in 28, stage III in 111, and stage IV in 14. The operative mortality rate was 1.4% (3 patients), and complications occurred in 83 patients (37.7%). Follow-up was 98.6% complete. Median survival for operative survivors was 1.9 years (range, 32 days to 8.7 years). The overall 5-year survival rate was 25.2%; it was 80% for patients in stage 0, 94.4% for those in stage I, 36.0% for those in stage IIa, 14.3% for patients in stage IIb, 10% for those in stage III and 0% for patients in stage IV. CONCLUSIONS: Ivor Lewis esophagogastrectomy for esophageal cancer is a safe operation. Long-term survival is stage dependent. The low survival associated with advanced cancers should stimulate the search for effective neoadjuvant therapy.
BACKGROUND: Factors affecting the incidence of empyema and bronchopleural fistula (BPF) after pneumonectomy were analyzed. METHODS: All patients who underwent pneumonectomy at the Mayo Clinic in Rochester, Minnesota, from January 1985 to September 1998 were reviewed. There were 713 patients (514 males and 199 females). Ages ranged from 12 to 86 years (median 64 years). Indication for resection was primary malignancy in 607 patients (85.1%), metastatic disease in 32 (4.5%), and benign disease in 74 (10.4%). One hundred fifteen patients (16.1%) underwent completion pneumonectomy. Factors affecting the incidence of postoperative empyema and BPF were analyzed using univariate and multivariate analysis. RESULTS: Empyema was documented in 53 patients (7.5%; 95% confidence interval [CI], 5.7% to 9.7%) and a BPF in 32 (4.5%; 95% CI, 3.1% to 6.3%). Univariate analysis demonstrated that the development of empyema was adversely affected by benign disease (p = 0.0001), lower preoperative forced expiratory volume in 1 second (FEV1; p < 0.01) and diffusion capacity of lung to carbon monoxide (DLCO; p = 0.0001), lower preoperative serum hemoglobin (p = 0.05), right pneumonectomy (p = 0.0109), bronchial stump reinforcement (p = 0.007), completion pneumonectomy (p < 0.01), timing of chest tube removal (p = 0.01), and the amount of blood transfusions (p < 0.01). Similarly, the development of BPF was significantly associated with benign disease (p = 0.03), lower preoperative FEV1 (p = 0.03) and DLCO (p = 0.01), right pneumonectomy (p < 0.0001), bronchial stump reinforcement (p = 0.03), timing of chest tube removal (p = 0.004), increased intravenous fluid in the first 12 hours (p = 0.04), and blood transfusions (p = 0.04). Bronchial stump closure with staples had a protective effect against BPF compared with suture closure (p = 0.009). No risk factors were identified as being jointly significant in multivariate analysis. CONCLUSIONS: Multiple perioperative factors were associated with an increased incidence of empyema and BPF after pneumonectomy. Prophylactic reinforcement of the bronchial stump with viable tissue may be indicated in those patients suspected at higher risk for either empyema or BPF.
BACKGROUND: The objective of this study was to analyze our initial results after laparoscopic repair of large paraesophageal hiatal hernias. METHODS: Between October 1997 and May 2000, 37 patients (23 women, 14 men) underwent laparoscopic repair of a large type II (pure paraesophageal) or type III (combined sliding and paraesophageal) hiatal hernia with more than 50% of the stomach herniated into the chest. Median age was 72 years (range 52 to 92 years). Data related to patient demographics, esophageal function, operative techniques, postoperative symptomatology, and complications were analyzed. RESULTS: Laparoscopic hernia repair and Nissen fundoplication was possible in 35 of 37 patients (95.0%). Median hospitalization was 4 days (range 2 to 20 days). Intraoperative complications occurred in 6 patients (16.2%) and included pneumothorax in 3 patients, splenic injury in 2, and crural tear in 1. Early postoperative complications occurred in 5 patients (13.5%) and included esophageal leak in 2, severe bloating in 2, and a small bowel obstruction in 1. Two patients died within 30 days (5.4%), 1 from delayed splenic bleeding and 1 from adult respiratory distress syndrome secondary to a recurrent strangulated hiatal hernia. Follow-up was complete in 31 patients (94.0%) and ranged from 3 to 34 months (median 15 months). Twenty-seven patients (87.1%) were improved. Four patients (12.9%) required early postoperative dilatation. Recurrent paraesophageal hiatal hernia occurred in 4 patients (12.9%). Functional results were classified as excellent in 17 patients (54.9%), good in 9 (29.0%), fair in 1 (3.2%), and poor in 4 (12.9%). CONCLUSIONS: Laparoscopic repair of large paraesophageal hiatal hernias is a challenging operation associated with significant morbidity and mortality. More experience, longer follow-up, and further refinement of the operative technique is indicated before it can be recommended as the standard approach.
INTRODUCTION: Announcing to a patient that he has cancer is a key moment both in the relationship between this patient and his doctor and in the setting up of quality communications. However, the quality of this communication is often impaired by the presence of paradoxes and misunderstandings. CURRENT KNOWLEDGE AND KEY POINTS: The particularities of cancer, the defense mechanisms of the different contributors and cancer representations can increase the sources of misunderstandings, which will leave an indelible mark on the patient at the beginning of the disease. FUTURE AND PROJECTS: What's at stake in that type of announcement in terms of compliance should not be neglected. Practitioners becoming aware of those phenomena and communication rules should improve the modes of announcement.
Empyema after pneumonectomy is often associated with a bronchopleural fistula (BDF) and has a significant mortality. Management options include systemic antibiotics and observation, adequate pleural drainage, appropriate parenteral antibiotics, removal of necrotic tissue, and obliteration of residual pleural space. We prefer to treat the empyema with the procedure originally described by Clagett and Geraci in 1963. They demonstrated that postpneumonectomy empyema could be successfully treated by open pleural drainage, frequent wet-to-dry dressing changes, and when the thorax was clean, secondary chest wall closure with obliteration of the pleural cavity with an antibiotic solution. Failure was most often caused by a persistent or recurrent fistula. Because of this, when a BPF is present, the original Clagett technique was modified to include transposition of a well-vascularized muscle to cover the stump at the time of open drainage to prevent further ischemia and necrosis. Our preference is intrathoracic transposition of extrathoracic skeletal muscle. The goals of therapy for postpneumonectomy empyema remain a healthy patient with a a healed chest wall and no evidence of drainage or infection. Excellent results can be obtained in more than 80% of patients by using the Clagett procedure and intrathoracic muscle transposition when a BPF is present.
BACKGROUND: Preoperative identification of lymph node metastases associated with esophageal carcinoma may influence treatment. EUS is the most accurate method for locoregional staging of these tumors. The impact of EUS-guided fine-needle aspiration (EUS-FNA) on lymph node staging in esophageal carcinoma is unclear. METHODS: From May 1996 to May 1999, 74 patients with esophageal carcinoma underwent preoperative EUS. After October 1998 EUS-guided FNA was performed on nonperitumoral lymph nodes greater than 5 mm in width. The results of EUS with and without FNA were retrospectively reviewed and compared. Final diagnosis was based on surgical results or EUS-guided FNA malignant cytology. Ten of the 74 patients had to be excluded for lack of lymph node stage confirmation. Final diagnosis was obtained in the remaining 64 patients (33 from the EUS only group and 31 from the EUS-FNA group). RESULTS: The results of EUS versus EUS-FNA for lymph node staging were sensitivity 63% versus 93% (p = 0.01), specificity 81% versus 100% (not significant), and accuracy 70% versus 93% (p = 0.02), respectively. Complications comprised 1 patient who developed self-limited bleeding after dilation that did not preclude completion of the EUS (1%, 95% CI [0%, 7%]). CONCLUSIONS: EUS-FNA is more sensitive and accurate than EUS alone for preoperative staging of locoregional and celiac lymph nodes associated with esophageal carcinoma. EUS-FNA of nonperitumoral lymph nodes in patients with esophageal carcinoma is safe and should be routinely performed when treatment decisions will be affected by nodal stage.
OBJECTIVE: The rate of complete resection (50%) and the 5-year survival (30%) for non-small cell lung carcinomas of the superior sulcus have not changed for 40 years. Recently, combined modality therapy has improved outcome in other subsets of locally advanced non-small cell lung carcinoma. This trial tested the feasibility of induction chemoradiation and surgical resection in non-small cell lung carcinoma of the superior sulcus with the ultimate aim of improving resectability and survival. METHODS: Patients with mediastinoscopy-negative T3-4 N0-1 superior sulcus non-small cell lung carcinoma received 2 cycles of cisplatin and etoposide chemotherapy concurrent with 45 Gy of radiation. Patients with stable or responding disease underwent thoracotomy 3 to 5 weeks later. All patients received 2 more cycles of chemotherapy and were followed up by serial radiographs and scans. Survival was calculated by the Kaplan-Meier method and prognostic factors were assessed for significance by Cox regression analysis. RESULTS: From April 1995 to September 1999, 111 eligible patients (77 men, 34 women) were entered in the study, including 80 (72.1%) with T3 and 31 with T4 tumors. Induction therapy was completed as planned in 102 (92%) patients. There were 3 treatment-related deaths (2.7%). Cytopenia was the main grade 3 to 4 toxicity. Of 95 patients eligible for surgery, 83 underwent thoracotomy, 2 (2.4%) died postoperatively, and 76 (92%) had a complete resection. Fifty-four (65%) thoracotomy specimens showed either a pathologic complete response or minimal microscopic disease. The 2-year survival was 55% for all eligible patients and 70% for patients who had a complete resection. To date, survival is not significantly influenced by patient sex, T status, or pathologic response. CONCLUSIONS: (1) This combined modality treatment is feasible in a multi-institutional setting; (2) the pathologic complete response rates were high; and (3) resectability and overall survival were improved compared with historical experience, especially for T4 tumors, which usually have a grim prognosis.
OBJECTIVE: The purpose of this report is to analyze factors affecting morbidity and mortality after pneumonectomy for malignant disease. METHODS: We retrospectively reviewed the cases of all patients who underwent pneumonectomy for malignancy at the Mayo Clinic. Between January 1, 1985, and September 30, 1998, 639 patients (469 men and 170 women) were identified. Median age was 64 years (range 20 to 86 years). Indication for pneumonectomy was primary lung cancer in 607 (95.0%) patients and metastatic disease in 32 (5.0%). Factors affecting morbidity and mortality were analyzed by univariate and multivariate analysis. RESULTS: Cardiopulmonary complications occurred in 245 patients (38.3%; 95% confidence interval 34.6%-42.2%). Factors adversely affecting morbidity with univariate analysis included age (P <.0001), male sex (P =.04), associated respiratory (P =.02) or cardiovascular disease (P <.0001), cigarette smoking (P =.02), decreased vital capacity (P =.01), forced expiratory volume in 1 second (P <.0001), forced vital capacity (P =.002), diffusion capacity of the lung to carbon monoxide (P =.005), oxygen saturation (P <.05), arterial PO (2) (P =.007), preoperative radiation (P =.02), bronchial stump reinforcement (P =.007), crystalloid infusion (P =.01), and blood transfusion (P =.02). Factors adversely affecting morbidity with multivariate analysis included age (P =.0001), associated cardiovascular disease (P =.001), and bronchial stump reinforcement (P =.0005). There were 45 deaths (7.0%; 95% confidence intervals 5.2%-9.3%). Factors adversely affecting mortality with univariate analysis included associated cardiovascular (P <.0001) or hematologic disease (P <.005), lower preoperative serum hemoglobin level (P =.004), preoperative chemotherapy (P =.01), decreased diffusion capacity of lung to carbon monoxide (P =.002), right pneumonectomy (P =.0006), extended resection (P =.04), bronchial stump reinforcement (P =.007), and crystalloid infusion (P =.01). Factors affecting mortality with multivariate analysis included hematologic disease (P =.01), lower preoperative serum hemoglobin (P =.003), and completion pneumonectomy (P =.01). CONCLUSION: Multiple factors adversely affected morbidity and mortality after pneumonectomy for malignant disease. Appropriate selection and meticulous perioperative care are paramount to minimize risks in those patients who require pneumonectomy.
OBJECTIVES: The role of surgical resection for brain metastases from non-small cell lung cancer is evolving. Although resection of primary lung cancer and metachronous brain metastases is superior to other treatment modalities in prolonging survival and disease-free interval, resection of the primary non-small cell lung cancer and synchronous brain metastases is controversial. METHODS: From January 1975 to December 1997, 220 patients underwent surgical treatment for brain metastases from non-small cell lung cancer at our institution. Twenty-eight (12.7%) of these patients underwent surgical resection of synchronous brain metastases and the primary non-small cell lung cancer. RESULTS: The group comprised 18 men and 10 women. Median age was 57 years (range 35-71 years). Twenty-two (78.6%) patients had neurologic symptoms. Craniotomy was performed first in all 28 patients. Median time between craniotomy and thoracotomy was 14 days (range 4-840 days). Pneumonectomy was performed in 4 patients, bilobectomy in 4, lobectomy in 18, and wedge excision in 2. Postoperative complications developed in 6 (21.4%) patients. Cell type was adenocarcinoma in 11 patients, squamous cell carcinoma in 9, and large cell carcinoma in 8. After pulmonary resection, 17 patients had no evidence of lymph node metastases (N0), 5 had hilar metastases (N1), and 6 had mediastinal metastases (N2). Twenty-four (85.7%) patients received postoperative adjuvant therapy. Follow-up was complete in all patients for a median of 24 months (range 2-104 months). Median survival was 24 months (range 2-104). Survival at 1, 2, and 5 years was 64.3%, 54.0%, and 21.4%, respectively. The presence of thoracic lymph node metastases (N1 or N2) significantly affected 5-year survival (P =.001). CONCLUSION: Although the overall survival for patients who have brain metastases from non-small cell lung cancer is poor, surgical resection may prove beneficial in a select group of patients with synchronous brain metastases and lung cancer without lymph node metastases.