Biomedical subjects

M D'Angelica

Publications and source records attributed to M D'Angelica.

15 recordsLinked to original sources

PubMed2005

Initial experience with hand-assisted laparoscopic distal pancreatectomy.

BACKGROUND: Hand-assisted laparoscopic distal pancreatectomy, with or without splenectomy, is gradually gaining acceptance, although its ultimate benefit is yet to be confirmed. This study aimed to report our initial experience with hand-assisted laparoscopic distal pancreatectomy. METHODS: A retrospective review of a prospectively collected database including 17 patients during the period 2002-2004 was conducted. The median age was 60 years (range, 29-85 years), and the female-to-male ratio was 13:4. The preoperative diagnoses included benign and malignant conditions. Besides two to three ports, a hand port was placed in the upper midline to aid in dissection. The pancreas was divided with a stapler in all the patients, and drains were placed in 10 patients (70%). RESULTS: One patient was found to be unresectable because of celiac artery involvement, and 2 of the remaining 16 patients underwent conversion to an open procedure. The median operating time was 196 min (range, 128-235 min). The mean tumor size was 4 cm (range, 2-7 cm), and the estimated blood loss was 125 ml (range, 50-1,250 ml). The median time to resumption of a regular diet was 3.5 days (range, 2-9 days), and the time to conversion to oral pain medications was 3 days (range, 2-9 days). The length of hospital stay was 5.5 days (range, 4-18 days), with a majority of the patients (11 patients, 78%) staying less than 7 days. There were no mortalities. The overall postoperative morbidity rate was 25%, and the morbidities consisted of pancreatic leak/fistula (2 patients, 14%) and fever (1 patient). The margins were negative in 10 (76%) of the relevant 13 patients. At a median follow-up period of 3.8 months (range, 5-14 months), 11 (84%) of 13 patients had no evidence of disease recurrence. CONCLUSIONS: The minimally invasive approach to pancreatic disease is safe and technically feasible. Further large studies with longer follow-up periods are necessary to determine the role of laparoscopic surgery in the management of pancreatic disease.

Adult↗

PubMed2003

The role of staging laparoscopy in hepatobiliary malignancy: prospective analysis of 401 cases.

BACKGROUND: Patients with potentially resectable hepatobiliary malignancy are frequently found to have unresectable tumors at laparotomy. We prospectively evaluated staging laparoscopy in patients with resectable disease on preoperative imaging. METHODS: Staging laparoscopy was performed on 410 patients with potentially resectable hepatobiliary malignancy. The preoperative likelihood of resectability was recorded. Data on preoperative imaging, operative findings, and hospital course were analyzed. RESULTS: Laparoscopic inspection was complete in 291 (73%) patients. In total, 153 patients (38%) had unresectable disease, 84 of whom were identified laparoscopically, increasing resectability from 62% to 78%. On multivariate analysis, a complete examination, preoperative likelihood of resection, and primary diagnosis were significant predictors of identifying unresectable disease at laparoscopy. The highest yield was for biliary cancers, and the lowest was for metastatic colorectal cancer. In patients with unresectable disease identified at laparoscopy, the mean hospital stay was 3 days, and postoperative morbidity was 9%, compared with 8 days and 27%, respectively, in patients found to have unresectable disease at laparotomy. CONCLUSIONS: Laparoscopy spared one in five patients a laparotomy while reducing hospital stay and morbidity. Targeting laparoscopy to patients at high risk for unresectable disease requires consideration of disease-specific factors; however, the surgeons' preoperative impression of resectability is also important.

Aged↗

PubMed2002

Staging laparoscopy for potentially resectable noncolorectal, nonneuroendocrine liver metastases.

BACKGROUND: Carefully selected patients with noncolorectal, nonneuroendocrine (NCNN) liver metastases may benefit from hepatic resection. The incidence of occult unresectable disease and the possible benefits of staging laparoscopy in these patients are not known. METHODS: From December 1997 to July 2000, staging laparoscopy was performed in 30 consecutive patients with NCNN metastases before planned open exploration and resection. Demographics, extent of preoperative imaging, operative and postoperative findings, and factors associated with laparoscopic identification of unresectable disease were analyzed. RESULTS: Twenty-four patients (80%) had a complete laparoscopic examination, and 23 had laparoscopic ultrasonography. All patients underwent preoperative computed tomography or magnetic resonance imaging, and 21 (70%) patients had 2 or more preoperative radiological studies. Overall, nine patients had unresectable disease, six of whom were identified by laparoscopy. Of the remaining 24 patients believed to have resectable disease at laparoscopy, 21 went on to a potentially curative procedure. Laparoscopy did not identify irresectability because of vascular involvement in three patients. Laparoscopy added a median of 30 minutes of operative time to those patients going on to laparotomy. CONCLUSIONS: Laparoscopy identified the majority of patients with occult unresectable disease, improved resectability, and should be routine in patients being considered for potentially curative hepatic resection.

Adult↗

PubMed2001

Beyond requirements: residency management through the Internet.

HYPOTHESIS: An Internet application could collect information to satisfy documentation required by the Residency Review Committee. Beyond replacing a difficult and inefficient paper system, it would collect, process, and distribute information to administration, faculty, and residents. DESIGN: Descriptive study. SETTING: An integrated residency of 18 services at a university teaching hospital with 4 affiliated institutions. PARTICIPANTS: Residency administrators, faculty, and residents. INTERVENTIONS: The application included a procedure recorder, resident evaluation of faculty and rotations, goals and objectives (stratified by service and resident level), and matching faculty evaluation of residents with these goals as competencies. Policies, schedules, research opportunities, clinical site information, and curriculum support were created. MAIN OUTCOME MEASURES: Degree of compliance with Residency Review Committee standards, number of deficiencies corrected, and quantity and quality of information available to administration, faculty, and residents. RESULTS: The Internet system increased resident compliance for faculty and rotation evaluations from 20% and 34%, respectively, to 100%, which was maintained for 22 months. These evaluations can be displayed individually, in summary grids, and as postgraduate year-specific averages. Faculty evaluations of residents can be reviewed throughout the system. The defined category report for procedures, which had deficiencies in the preceding 6 years, had none for the last 2 years. The Internet application provides Accreditation Council for Graduate Medical Education-validated operative logs to regulatory agencies. CONCLUSIONS: A Web-based system can satisfy requirements and provide processed data that are of better quality and more complete than our paper system. We are now able to use scarce time and personnel to nurture developing surgical residents instead of shuffling paper.

Connecticut↗

PubMed2000

A quantitative assessment of liver metabolites during jaundice using three dimensional phosphorus chemical shift imaging.

Phosphorus metabolites in the jaundiced rat liver were studied by three-dimensional phosphorus chemical shift imaging (CSI). Animals were studied at 1, 2, and 3 weeks post-ligation of the common bile duct. Quantitation of metabolites was performed using an external standard. Metabolite T(1) values were assessed in CSI experiments on normal untreated animals. High-performance liquid chromatography (HPLC) was used to measure adenine nucleotides in a separate group of jaundiced rats. 3D-CSI did not detect significant changes in NTP in jaundiced animals relative to baseline controls. At two and three weeks post bile duct ligation, pH was significantly elevated. HPLC data comparing ATP levels to baseline controls also detected no change except for elevated ATP detected on Day 21. (31)P NMR chemical shift imaging may be used to assess liver metabolites under conditions of stress such as jaundice. However, absolute quantitation requires careful attention to many factors including point spread function, correct T(1) values, and adequate signal-to-noise ratio.

Adenosine Triphosphate↗

PubMed2000

Efficient cotransduction of tumors by multiple herpes simplex vectors: implications for tumor vaccine production.

Many gene therapy strategies would be enhanced by efficient transfer of multiple genes into the same cell. Herpes simplex viral amplicon (HSV) vectors are good vehicles for gene transfer because they accommodate large pieces of foreign DNA and transfer genes rapidly and efficiently. The current studies examine whether efficient cotransduction of tumor cells can be accomplished using multiple HSV vectors in a manner useful for clinical gene therapy. Interleukin-12 (IL-12) exists as a heterodimer, with components (m35 and m40) coded for by genes on two separate chromosomes. We constructed HSV vectors carrying either IL12m35 (HSVm35) or IL12m40 (HSVm40) or both genes (HSVm75) separated by an internal ribosome entry site to assess whether gene transfer using a single HSV vector constructed to carry multiple genes has any advantage over gene transfer using multiple vectors that are each carrying single genes. Because IL-12 and IL-2 have been found to have synergistic antitumoral activity, we further analyzed the biologic activity of tumor cells cotransduced by separate HSV vectors carrying genes coding for these two cytokines. The results demonstrate that multiple genes can be inserted into the same cell efficiently using multiple HSV vectors, and that these vectors allow rapid production of tumor vaccines expressing multiple cytokine genes. Thus, gene transfer using HSV may not be limited by the size of the DNA that each vector can accommodate. Immunizations with tumors cotransduced with HSVm35 and HSVm40 were equally effective in eliciting a cytolytic T-lymphocyte response and in protecting against tumor growth in vivo as immunization with tumors treated with HSVm75. Immunization with tumors cotransduced with HSVm75 and HSVil2 was superior to immunization with tumors transduced with either alone. The combination of IL-2- and IL-12-secreting tumor cells may be used as an effective immunization strategy against solid tumors.

Animals↗

PubMed1999

In vivo interleukin-2 gene therapy of established tumors with herpes simplex amplicon vectors.

In vivo cytokine gene transfer may greatly simplify autologous tumor vaccine production. Herpes simplex viral amplicon vectors (HSV) are efficient gene-transfer vehicles and may overcome many limitations of prior gene-transfer methods. The interleukin-2 (IL-2) and beta-galactosidase genes (lac) were inserted into an HSV amplicon vector and tested in a subcutaneous squamous cell carcinoma of lung origin to determine the efficiency of in vivo gene transfer and the utility of such a direct gene transfer approach in cancer therapy. Gene transfer and expression were assessed by histochemical staining and enzyme-linked immunosorbent assay (ELISA). Growth of injected tumors as well as non-injected tumors remote from the site of injection was assessed. Assessment of lymphocytic infiltrates into tumors was performed by immunohistochemistry. Survival was recorded. Direct in vivo injection of established tumors with a HSVi12 resulted in efficient gene transfer and production of IL-2 in the injected tumor but not at tumors remote from the sites of injection. There was a significant suppression of growth of the tumors injected with HSVi12 (P<0.01) when compared with tumors injected with HSV without i12. Of note, growth of tumors remote from sites of HSVi12 injection was also retarded and treatment was associated with a significant (P<0.05) improvement in survival. Direct intratumoral administration of HSV amplicon vectors can result in efficient transfer of cytokine genes and have antitumor efficacy. HSV vectors are therefore potentially useful agents in such in vivo gene-therapy strategies and simplify cytokine antitumor gene-therapy strategies.

Animals↗

PubMed1999

Herpes simplex virus (HSV)-mediated ICAM-1 gene transfer abrogates tumorigenicity and induces anti-tumor immunity.

BACKGROUND: Costimulatory and cellular adhesion molecules are thought to be essential components of antigen presentation in the immune response to cancer. The current studies examine gene transfer utilizing herpes viral amplicon vectors (HSV) to direct surface expression of adhesion molecules, and specifically evaluate the potential of a tumor-expressing intercellular adhesion molecule-1 (ICAM-1) to elicit an anti-tumor response. MATERIALS AND METHODS: The human ICAM-1 (hICAM1) gene was inserted into an HSV amplicon vector and tested in a transplantable rat hepatocellular carcinoma and in a human colorectal cancer cell line. Cell surface ICAM-1 expression was assessed by flow cytometry. Lymphocyte binding to HSV-hICAM1-transduced cells was compared with that to cells transduced with HSV not carrying the ICAM gene. Tumorigenicity of HSV-hICAM1-transduced tumor cells were tested in syngeneic Buffalo rats. Additionally, immunization with irradiated (10,000 rads) HSV-hICAM1-transduced tumor cells was performed to determine its effect on tumor growth. RESULTS: A 20-min exposure of tumor cells at a multiplicity of infection (MOI) of 1 resulted in high-level cell surface expression of human ICAM in approximately 25% of tumor cells. Transduced rat or human tumor cells exhibited significantly enhanced binding of lymphocytes (p < 0.05). HSV-hICAM1-transduced cells elicited an increase in infiltration by CD4(+) lymphocytes in vivo and exhibited decreased tumorigenicity. Immunization with irradiated HSV-hICAM1-transduced cells protected against growth of subsequent injected parental tumor cells. CONCLUSIONS: HSV amplicon-mediated gene transfer is an efficient method for modifying the cell surface expression of adhesion molecules. Increased tumor expression of ICAM-1 represents a promising immune anti-cancer strategy.

Animals↗

PubMed1998

The effects of hepatic cryosurgery on tumor growth in the liver.

BACKGROUND: The effects of hepatic cryosurgery on residual hepatic tumor growth, and on tumor immunity, have not been determined. MATERIALS AND METHODS: Two experiments were performed. In both, animals (n = 10 per group) had solitary left lobe hepatomas established, and underwent left lobectomy, cryoablation, or control laparotomy. Experiment I: immediately after tumor treatment, intraportal challenge of hepatoma cells was performed to evaluate for the effects of treatment on residual hepatic tumor growth. Experiment II: animals were challenged 14 days after tumor treatment, and splenocyte cytotoxicity assays were performed to evaluate for tumor immunity. Hepatic tumor nodules were counted 3 weeks after challenge in both experiments. RESULTS: In animals challenged immediately after tumor treatment, the mean number of liver nodules at 3 weeks was similar between control and cryoablation groups (65 +/- 13 vs 115 +/- 38, P = 0.17). Animals that had undergone resection, however, had a significant increase in the mean number of nodules as compared to cryoablation (278 +/- 74 vs 115 +/- 38, P = 0. 04) and control (278 +/- 74 vs 65 +/- 13, P = 0.002) animals. In addition, only resection animals had elevation in serum levels of the growth factor FGF-basic, 48 h after treatment (mean = 30 +/- 14 pg/ml). In animals challenged 14 days following treatment, all groups had similar numbers of nodules (resection vs cryoablation, P = 0.8). Splenocyte cytotoxicity was not increased after cryosurgical treatment. CONCLUSIONS: Unlike partial hepatectomy, cryoablation of hepatomas in rats does not accelerate residual tumor growth in the liver or result in production of the growth factor FGF-basic. We did not find evidence for the development of tumor immunity following cryosurgery.

Alanine Transaminase↗

PubMed1998

Surgeon-patient communication in the treatment of pancreatic cancer.

BACKGROUND: Effective physician-patient communication has been correlated with patient satisfaction and improved outcome. Pancreatic cancer (PC) is a disease with an overwhelmingly poor prognosis that requires a complex level of communication and emotional support. Since the treatment of PC is often surgical, surgeons play a central role in the care of these patients. OBJECTIVES: To assess the quality of long- and short-term surgeon-patient communication. To assess the role of the surgeon in the emotional support of patients with PC. DESIGN: Combined mail and telephone survey of a case series of patients who had undergone a pancreatic resection for PC. SETTING: Urban tertiary cancer referral center. PATIENTS: Forty-eight patients who underwent pancreatic resection for PC. INTERVENTION: Pancreatic resection. MAIN OUTCOME MEASURE: Patient satisfaction. RESULTS: Forty-eight patients completed surveys for a response rate of 70%. Patients were extremely satisfied with the information provided by their surgeon before surgery and while in the hospital. However, 21% of patients reported an unexpected outcome of their operation and 27% had questions about their disease at the time of the survey. Patients were largely satisfied with the emotional support they had received while in the hospital and after discharge. The attending surgeon was the most commonly desired source of additional emotional support. CONCLUSIONS: While surgeon-patient communication was extremely effective before surgery and during hospitalization, patients developed long-term questions and dissatisfaction after discharge from the hospital. Strategies to improve long-term support and communication would benefit a significant number of patients with operable PC. Surgeons play an important role in the emotional support of patients with operable PC.

Adult↗

PubMed1998

Isolated hepatic splenosis: first reported case.

Splenosis is the autotransplantation of splenic tissue, most commonly seen after traumatic splenic rupture and splenectomy. Post-traumatic splenosis is often considered a rare entity, but is probably underreported because of its asymptomatic nature. We describe the first reported case of splenosis presenting as a liver mass, indistinguishable from a liver tumor by standard preoperative evaluation. The pathophysiology, evaluation and management of splenosis is discussed as well as the decision to resect a benign appearing liver mass.

Adult↗

PubMed1998

Cytokine gene therapy for human tumors.

Cytokine gene therapy is a potentially powerful antineoplastic strategy. It provides paracrine cytokine secretion in the region of putative tumor antigen that maximizes antitumor immune responses and minimizes systemic toxicity. A wealth of animal experimentation has demonstrated the effectiveness of cytokine gene therapy in a variety of tumor models. Enough evidence has mounted such that human cytokine gene therapy trials are underway throughout the United States and elsewhere.

Cancer Vaccines↗

PubMed1997

Prevention of hepatic tumor metastases in rats with herpes viral vaccines and gamma-interferon.

Previous studies showed that gammaIFN decreases metastatic hepatic tumor growth by stimulating Kupffer cells (KC). The present studies examine whether lymphocyte stimulation via cells engineered to secrete GM-CSF or IL-2 decreases hepatic tumor growth, and whether stimulation of both macrophages and lymphocytes is more effective than either individually. Rats were immunized with irradiated hepatoma cells transduced by herpes viral amplicon vectors containing the genes for GM-CSF, IL-2 or LacZ. On day 18, half of each group was treated with 5 x 10(4) U gammaIFN, or saline intraperitoneally for 3 d. On day 21, all rats received 5 x 10(5) hepatoma cells intrasplenically. On day 41, rats were killed and tumor nodules were counted. Separate rats underwent splenocyte and KC harvest for assessment of lymphocyte- and macrophage-mediated tumor cell kill in vitro. GM-CSF or IL-2 vaccines or gammaIFN decreased tumor nodules significantly (GM-CSF 13+/-4, IL-2 14+/-6 vs. control 75+/-24, P < 0.001). Combination therapy was more effective, and completely eliminated tumor in 4 of 12 IFN-GM-CSF and 8 of 11 IFN-IL-2 animals. Additional rats underwent partial hepatectomy, an immunosuppressive procedure known to accelerate the growth of hepatic tumor, following tumor challenge. Therapy was equally effective in this immunosuppressive setting. Vaccination is associated with enhancement of splenocyte-mediated tumoricidal activity, whereas the effect of gammaIFN is mediated by KC. GM-CSF and IL-2 vaccine therapy and pretreatment with gammaIFN represent effective strategies in reducing hepatic tumor. Combination therapy targets both lymphocytes and macrophages, and is more effective in reducing tumor than either therapy alone.

Animals↗

PubMed1997

Ninety-six five-year survivors after liver resection for metastatic colorectal cancer.

BACKGROUND: Studies have consistently confirmed the benefit of liver resection for metastatic colorectal cancer. Few reports, however, have a long enough followup or sufficient 5-year survivors to study the clinical course of patients beyond 5 years. STUDY DESIGN: From July 1985 through December 1991, 456 patients underwent liver resection for colorectal metastases. Ninety-six actual 5-year survivors (21%) were identified and their clinical course retrospectively reviewed. RESULTS: Five-year survivors (n = 96) were more likely to have a Duke's B primary colorectal carcinoma, fewer than four metastatic lesions, unilobar disease, and a negative histologic margin when compared with patients not surviving 5 years (n = 298). Forty-four (46%) of the 96 five-year survivors had a recurrence after hepatectomy. Of these 44, 19 (43%) were rendered disease free after further treatment. Overall, 71 of the 96 five-year survivors were free of disease at last followup. The actuarial 10-year survival of this group was 78%. CONCLUSIONS: Patients that are disease free 5 years after liver resection are likely to have been cured by liver resection. Patients should be aggressively followed for recurrence because of the potential for further treatment and longterm survival.

Adult↗

PubMed1995

Hypopituitarism secondary to transfacial gunshot wound.

Hypopituitarism secondary to penetrating head trauma is extremely rare, and its diagnosis may be delayed for several years. We present a patient who developed hypopituitarism secondary to a transfacial gunshot wound and who experienced damage to the hypophysis secondary to transmission of energy and bullet fragments. The importance of a computerized tomographic scan of the head in facial gunshot wound is discussed.

Adult↗