[Colonic polyps inoperable by endoscopy: value of celioscopic segmental colectomy].
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Aged↗
Biomedical subjects
C Smadja
Publications and source records attributed to C Smadja.
Results of major hepatectomy for large primary liver cancer in patients with cirrhosis.
Major hepatectomy is associated with a high operative risk in patients with cirrhosis. Between June 1983 and December 1991, 33 cirrhotic patients, 31 with good liver function, underwent major liver resection for a large hepatic primary cancer. The hospital mortality rate was 3 per cent; the only death resulted from liver failure after extended right hepatectomy. None of the patients had variceal bleeding during the postoperative period. Survival rates at 1, 2 and 3 years were 66, 43 and 37 per cent respectively. Recurrence was the most common reason for late death. These results suggest that the operative risk of major hepatectomy in cirrhotic patients with a large tumour and good liver function is comparable to that of minor liver resection. Late survival is also similar to that of patients with a small tumour. Cirrhotic patients with hepatic carcinoma and good liver function are suitable for major hepatectomy.
Adult↗
Role of endogenous cholecystokinin in the facilitation of mu-mediated antinociception by delta-opioid agonists.
Published results suggest that delta-opioid agonists can modulate the mu-mediated analgesia. In this work, the antinociceptive effects produced by the mu agonist [D-Ala2,NMe-Phe4,Gly-ol5]enkephalin or the mixed inhibitor of enkephalin-degrading enzymes RB 101 (N- [(R,S)-2-benzyl-3[(S)(2-amino-4-methyl- thio)butyldithio]-1-oxopropyl]-L-phenylalanine benzyl ester) were studied after administration of the systemically active and selective delta agonist Tyr-D-Ser(O-tert-butyl)-Gly-Phe-Leu- Thr(O-tert-butyl). In the hot-plate test in mice, Tyr-D-Ser(O-tert-butyl)-Gly- Phe-Leu-Thr(O-tert-butyl) (i.v.) potentiated the antinociceptive responses elicited by [D-Ala2,NMe-Phe4,Gly-ol5]enkephalin (i.v.) or RB 101 (i.v.). These facilitatory effects were reversed not only by prior administration of the delta-selective antagonist naltrindole (0.5 mg/kg s.c.), but also unexpectedly by the selective cholecystokinin CCK-A antagonist MK-329 (20 micrograms/kg i.p.). In addition, the CCK analog [Boc- Tyr(SO3H)-Nle-Gly-Trp-Nle-Asp-Phe-NH2] (a mixed CCK-A/CCK-B agonist) increased the jump latency and this effect was blocked by MK-329 (20 micrograms/kg i.p.) and by naloxone, but not by the selective CCK-B antagonist L-365,260 (5 mg/kg i.p.). In contrast, the selective CCK-B agonist BC 264 (62 micrograms/kg i.v.) produced a hyperalgesic effect that was antagonized by L-365,260 (5 mg/kg i.p.). Taken together, these findings suggest that the potentiating effects of delta agonists on mu-mediated analgesia are due to an increase in the release of endogenous CCK interacting with CCK-A and CCK-B receptors and resulting in positive and negative regulation of the endogenous opioid system.(ABSTRACT TRUNCATED AT 250 WORDS)
Amino Acid Sequence↗
The Sugiura procedure: a prospective experience.
BACKGROUND: The Sugiura procedure, which includes esogastric devascularization, splenectomy, and esophageal transection, aims to suppress esophageal varices without exposing the patient to hepatic encephalopathy, because the operation does not alter hepatic blood flow. METHODS: From May 1978 to March 1989, 39 patients (79% with cirrhosis) with previous variceal bleeding underwent an elective Sugiura procedure. Thirteen of them (33%) had recurrent bleeding despite medical therapy. RESULTS: There were neither operative deaths nor intraoperative complications. Eighteen patients (46%) had 19 postoperative complications, which were severe in 7 cases. During the second postoperative month, 68% of the patients had no visible varices at endoscopy. There was no alteration of liver function at 1 year after operation. Ninety-five percent, 85% and 76% of patients were free of recurrent variceal bleeding at 1, 3, and 5 years, respectively. None of the patients had chronic encephalopathy. One-, 3-, and 5-year survival rates were 95%, 70%, and 70%, respectively. Survival curves were not different in patients with and without cirrhosis. CONCLUSIONS: The Sugiura procedure carries a low operative risk and results in good prevention of recurrent variceal bleeding. Moreover, the liver function remains stable after operation and there is no significant risk of hepatic encephalopathy. This procedure should be reserved for failure of medical therapy.
Adult↗
[Complications of biliary calculi. Etiology, diagnosis, treatment].
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Acute Disease↗
Laparoscopic treatment without cholecystectomy for gallbladder perforation after liver biopsy.
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Biopsy↗
Peritoneovenous shunting of intractable ascites in patients with cirrhosis: improving results and predictive factors of failure.
BACKGROUND: The clinical results of peritoneovenous shunting have not been entirely satisfactory in spite of dramatic improvement of renal function and decrease of ascites. The purpose of this study is to determine whether certain modifications improved our results. METHODS: A modified LeVeen shunt was electively inserted in 56 patients who had cirrhosis with intractable ascites. In 24 patients (42.9%) the Child-Pugh's score was less than 9, and in 32 patients the score was 9 or above. Fourteen patients (25%) had previous variceal bleeding, and 15 patients (26.8%) had previous spontaneous bacterial peritonitis (SBP). LeVeen shunt was modified by the addition of a titanium venous catheter tip. Prophylactic antibiotic therapy was administered to all patients. RESULTS: No operative deaths occurred, and one patient had severe postshunt coagulopathy. Five patients (8.9%) experienced recurrent ascites resulting from blockage from the shunt. The cumulative rate of shunt blockage was 5.6% at 1 year and 12% at 2 years. Seventeen patients (30.3%) have recently had variceal bleeding. The cumulative risk of variceal bleeding was significantly higher in patients with a previous hemorrhage than in those patients without (p < 0.05). Eight patients (14.3%) had SBP after operation. The cumulative risk of SBP was higher in patients with a history of SBP than in those patients without, although the difference was not significant. Fifty-five percent of late deaths were related to variceal bleeding or to SBP. Overall cumulative 1- and 2-year survival rates were 67.2% and 55.2%, respectively. It was 82% and 71% in patients without previous variceal bleeding or SBP. CONCLUSIONS: These data suggest that peritoneovenous shunting might be beneficial only in selected patients. Previous variceal bleeding and/or SBP indicate liver transplantation in suitable patients.
Adult↗
Splanchnic and systemic hemodynamics in cirrhotic patients with refractory ascites. Effect of peritoneovenous shunting.
The splanchnic and systemic hemodynamics of 14 patients with refractory ascites were studied and were compared to those of 15 patients with ascites responding to medical treatment. Among the 14 patients, 10 were grade B and 4 C, according to the Pugh classification. Of the 15 patients, 5 were Pugh B and 10 C. In patients with refractory ascites, free hepatic venous pressure was significantly higher and hepatic venous pressure gradient was significantly lower than in patients with responsive ascites. Hepatic and azygos blood flows were not significantly different between the two groups. Cardiac output was lower in patients with refractory ascites (p less than 0.05) than in those with responsive ascites. In patients with refractory ascites, six months after peritoneovenous shunting, there was a significant reduction of wedged and free hepatic venous pressures and azygos blood flow. Cardiac output increased by 20 % (p less than 0.02). This study shows that hemodynamic alterations in patients with refractory ascites is the consequence of increased intraabdominal pressure due to chronic ascites. Six months after peritoneovenous shunting splanchnic and systemic hemodynamics became similar to those observed in patients without ascites.
Adult↗
Analysis of morbidity and mortality rates in right hepatectomy with the preoperative APACHE II score.
Morbidity and mortality rates in 70 patients who underwent major liver resection for liver tumors (primary and metastatic) were determined and correlated with the preoperative APACHE II score. Patients were divided into three groups according to their preoperative APACHE II score: low (0 to 3), mid (4 to 7), and high (8 and above). A higher score was closely correlated with increased postoperative morbidity and operative mortality rates. The group with low scores had a postoperative morbidity rate of 34% and a mortality rate of 0%, the group with mid scores had a postoperative morbidity rate of 54% and a mortality rate of 3%, and the group with high scores had a postoperative morbidity rate of 80% and a mortality rate of 20%. Age did not correlate with morbidity. It was therefore postulated that morbidity and mortality rates were related to the combination of points for abnormal physiologic variables and points for chronic health, or APACHE II score minus points for age. As the combination of these points increases the postoperative morbidity and operative mortality rates increase significantly (from 24% in the 0-point group to 69% in the greater than or equal to 3-point group). Also the two deaths occurred in the group with 3 or more points. The preoperative APACHE II score may be used by clinicians to evaluate before surgery the risk of postoperative morbidity and death in elective major liver surgery.
Adult↗
Initial glucose kinetics and hormonal response to a gastric glucose load in unrestrained post-absorptive and starved rats.
A gastric [U-14C]glucose load (4.8 mg/g body wt.) was delivered to unrestrained post-absorptive or 30 h-starved rats bearing peripheral and portal vein catheters and continuously perfused with [3-3H]glucose, in order to compare their metabolic and hormonal responses. In the basal state, portal and peripheral glycaemia were less in starved rats than in rats in the post-absorptive period (P less than 0.01), whereas blood lactate was similar. Portal insulinaemia (P less than 0.05) and protal glucagonaemia (P less than 0.005) were lower in starved rats, but insulin/glucagon ratio was higher in post-absorptive rats (P less than 0.005). The glucose turnover rate was decreased by starvation (P less than 0.005). After glucose ingestion, blood glucose was similar in post-absorptive and starved rats. A large portoperipheral gradient of lactate appeared in starved rats. Portal insulinaemia reached a peak at 9 min, and was respectively 454 +/- 68 and 740 +/- 65 mu-units/ml in starved and post-absorptive rats. Portal glucagonaemia remained stable, but was higher in post-absorptive rats (P less than 0.05). At 60 min after the gastric glucose load, 30% of the glucose was delivered at the periphery in both groups. The total glucose appearance rate was higher in starved rats (P less than 0.05), as was the glucose utilization rate (P less than 0.05), whereas the rate of appearance of exogenous glucose was similar. This was due to a non-suppressed hepatic glucose production in the starved rats, whereas it was totally suppressed in post-absorptive rats. At 1 h after the glucose load, the increase in both liver and muscle glycogen concentration was greater in starved rats. Thus short-term fasting induces an increased portal lactate concentration after a glucose load, and produces a state of liver insulin unresponsiveness for glucose production, whereas the sensitivity of peripheral tissues for glucose utilization is unchanged or even increased. This might allow preferential replenishment of the peripheral stores of glycogen.
Animals↗
Resection of hepatocellular carcinomas. Results in 72 European patients with cirrhosis.
This study was undertaken to determine the results of resection of hepatocellular carcinoma in cirrhotic patients in Europe, using the same criteria as in the Orient for detection, surgical management, and pathology of the tumors. Seventy-two patients had a liver resection. One- and 3-yr survival rates were 68% and 51%, respectively. Survival rate was significantly higher in Child's/Pugh's class A than in class B-C patients. Patients with a thickly encapsulated tumor lived longer than those with an infiltrating tumor and had in addition a significantly lower incidence of cancer recurrence. Class A patients with a thickly encapsulated hepatocellular carcinoma had a 77% 3-year survival rate. There was no relation between the size of the tumor or the presence of symptoms and survival. These data suggest that good results can be achieved by resection of hepatocellular carcinomas in European cirrhotic patients. A thickly encapsulated tumor and an adequate liver function are the main determinants of low cancer recurrence and high survival. The clinical results in this series are similar to those reported from the Orient.
Adult↗
Effect of haemodilution on transfusion requirements in liver resection.
Between April, 1988, and February, 1989, 22 consecutive patients underwent liver resection (17 hepatectomy, 5 segmentectomy) with intraoperative haemodilution to avoid blood transfusion. The results were compared with those of 22 patients who underwent liver resection without haemodilution between February, 1987, and April, 1988, and who were matched for the nature of the tumour and the type of liver resection. Age, preoperative haematocrit and haemoglobin concentration, and intraoperative blood loss did not differ between the groups who did and did not undergo haemodilution. There was no abnormal bleeding during liver transection in haemodiluted patients. No allogeneic blood products at all were needed in a significantly greater proportion of the group with haemodilution than of the group without (19 [86%] vs 6 [27%]). The two groups also showed significant differences in the total requirements of allogeneic packed red cells (haemodilution 9 units, no haemodilution 84 units) and fresh frozen plasma (9 vs 119 units). Although the haematocrit was slightly but significantly lower in the group who underwent haemodilution than in those who did not on postoperative days 1 and 8, the differences had disappeared by the second postoperative month. Postoperative complication rates, abnormal results in liver biochemical tests, and lengths of hospital stay were the same in patients with and without haemodilution. Intraoperative haemodilution in patients undergoing liver resection reduced requirements for all blood products, further lowering the risks associated with liver resection.
Blood Transfusion↗
Improved early results of elective hepatic resection for liver tumors. One hundred consecutive hepatectomies in cirrhotic and noncirrhotic patients.
Liver resection for a neoplasm was performed in 100 patients between 1979 and 1987. There were 43 hepatocellular carcinomas (70% of them arising in patients with cirrhosis), 28 metastases from colorectal cancers, 20 benign tumors, and 9 miscellaneous tumors. Forty-nine patients had a major liver resection, 36 a segmentectomy, and 15 a nonanatomic liver resection. Great care was taken to avoid intraoperative and postoperative bleeding, including late ligation of the hepatic vein, the use of Kelly fracture and resorbable clips for hemostasis of transection planes in 74 patients, and temporary clamping of the portal pedicle in 22. Drainage of the abdomen was avoided in 21 patients to prevent ascitic leakage to decrease the postoperative hospital stay. Operative mortality was 1%. There were eight major complications, including one bile leak, one subphrenic abscess, and three subphrenic hematomas. The use of resorbable clips significantly reduced operative time and transfusion requirements. In patients with cirrhosis, temporary clamping of the hepatic pedicle significantly decreased blood loss. Avoiding drainage significantly decreased the postoperative hospital stay.
Adult↗
Morphological and histological features of resected hepatocellular carcinoma in cirrhotic patients in the West.
The pathological findings of 26 consecutive resections for hepatocellular carcinomas developing in cirrhotic patients were analyzed morphologically with a special interest in the presence of a capsule, vascular extension and satellite nodules. Tumor sizes varied from 2 to 11 cm. There were 20 expanding (76.9%) and six infiltrating tumors. Infiltrating tumors were significantly larger than expanding tumors (p less than 0.01). Histologically, the most common subgroups were the trabeculated pattern (65.4%) and the Edmonson-Steiner Type II (53.9%). Of the 20 expanding tumors, only six had direct spread in the liver parenchyma adjacent to the tumor (p less than 0.02). There was a significant relationship between the presence of a tumor extension in the distal portal branches and the presence of satellite nodules around the tumor (p less than 0.01). Survival at 6 months was significantly lower in patients with infiltrating (16.7%) than in those with expanding tumors (75%), (p less than 0.05). The present results indicate that pathological features of hepatocellular carcinomas in cirrhotic patients in Western countries are similar to those encountered in the East: (a) tumors are frequently encapsulated; (b) the propensity for the tumor to spread is closely related to the presence of a tumor capsule. This study suggests that a thorough preoperative search for the capsule should be made whenever resection of a hepatocellular carcinoma in a cirrhotic patient is contemplated.
Carcinoma, Hepatocellular↗
Hepatectomy without abdominal drainage. Results of a prospective study in 61 patients.
The increasingly simple postoperative course of major surgery has challenged the routine use of drainage after most abdominal surgical procedures. Therefore a prospective study was designed to determine if abdominal drainage could be safely avoided after liver resection and was evaluated in 61 consecutive patients. There was one postoperative death (1.7%) from variceal bleeding. Four other patients (6.7%) developed an abdominal complication: two right subphrenic hematomas requiring reoperation in one case and two incisional ascitic leaks requiring incisional repair in one patient. There was neither a subphrenic abscess nor bile peritonitis. Postoperative hospitalization was 11.5 +/- 3 days in the entire group and 8.5 +/- 1 days in patients without complications. These results suggest that liver resection can be performed safely without abdominal drainage and that the routine use of drains is unnecessary.
Abdomen↗
Development of VMH obesity: in vivo insulin secretion and tissue insulin sensitivity.
Euglycemic-hyperinsulinemic clamps coupled with an injection of [2-3H]deoxyglucose were performed in rats 1 or 6 wk after lesion of the ventromedial hypothalamus (VMH) and their age-matched controls. In the basal state, glucose utilization was not different in controls and VMH rats in all the tissues studied except in white adipose tissue where it was greatly increased after the lesion. When insulinemia was clamped at 850 microU/ml, glucose utilization was less important in glycolytic and normal in oxidative muscles in animals 1 wk after the lesion (VMH1) compared with controls. In animals 6 wk after the lesion (VMH6), all the muscles utilized less glucose than those of controls. In white adipose tissue, glucose utilization was increased twice more in VMH1 and returned to normal in VMH6. These data demonstrate a progressive development of insulin resistance in muscles. Simultaneously, there is a transient insulin hypersensitivity in white adipose tissue. This, together with a hypersecretion of insulin, could contribute to the development of body fat mass by redirecting glucose towards adipose tissue.
Adipose Tissue↗
Patterns of improvement in resection of hepatocellular carcinoma in cirrhotic patients: results of a non drainage policy.
A prolonged ascitic leak through abdominal drains is a source of postoperative complications and of prolonged postoperative hospital stay after liver resection for hepatocellular carcinoma (HCC) in cirrhotic patients. Therefore we elected to abstain from routine abdominal drainage in the last 14 resections in cirrhotic livers. A significantly smaller number of patients had postoperative complications following liver resections without drainage (7%) than historical controls with abdominal drainage (59%, p less than 0.01). The number of complications related to ascites was significantly greater in patients with abdominal drainage (76%) than without (0%, p less than 0.001). Postoperative hospital stay was also significantly longer following resections with abdominal drainage (19 +/- 4 days) than in patients without (12 +/- 1 days, p less than 0.01). The long postoperative hospital stay in patients with abdominal drainage was related to ascitic discharge for a mean period of 13 +/- 10 days. No clinically significant accumulation of ascites was noted in patients without drainage. A more frequent utilization of hepatic vascular inflow occlusion did not account for the better results in the group of patients without drainage. These results suggest that routine abdominal drainage should not be used following liver resection for HCC in cirrhotic patients. This appears to be another of the technical details improving postoperative results in these patients.
Adult↗
Long term results (greater than 5 years) in patients with peritoneovenous shunting for intractable ascites: liver function and cancer mortality.
This report is based on twenty-eight (26%) of 107 patients included in a protocol for prospective evaluation of elective peritoneo-venous shunting for intractable ascites in cirrhosis. These patients had no other procedures and survived more than 5 years after the operation. All patients were free of ascites except one in whom it was mild. One patient refused follow-up. Shunt patency was assessed in 23 patients In 14 patients (60.9%), the shunt was obstructed and the superior vena cava was occluded in 5 of them. In 9 patients (39.1%), the shunt was still functioning. No clinical or biological parameters differentiated these two groups of patients. Of the 24 patients who were alcoholics, 2 abstained completely and 20 significantly reduced their drinking habits. In 25 patients, the Pugh's score improved and was A at the time of the study. Seven patients (25.9%) developed a malignant tumor of the oro-pharynx or digestive tract, all other patients were alive and in good health. This study suggests that patients with intractable ascites treated by a peritoneo-venous shunt may survive for a long period. In patients abstaining from heavy drinking, it may function as a therapeutic bridge permitting spontaneous improvement of liver function. The risk of supervening neoplasms suggests that a continuous follow-up of these patients is warranted.
Adult↗