Biomedical subjects
F Penninckx
Publications and source records attributed to F Penninckx.
Healing of severe recurrent ileitis with azathioprine therapy in patients with Crohn's disease.
BACKGROUND & AIMS: Standard corticosteroid therapy for Crohn's ileitis induces symptom relief without improvement of endoscopically visible lesions. In this study, the effect of azathioprine therapy on the inflammatory lesions in the neoterminal ileum of patients with severe postoperative Crohn's recurrence was examined. METHODS: Macroscopic ileal lesions were studied endoscopically or radiologically after at least 6 months of azathioprine therapy after complete weaning of corticosteroids. All patients who underwent an ileocecal resection for Crohn's disease at our institution between January 1989 and December 1993 and who subsequently developed severe recurrent ileitis treated with azathioprine were included. RESULTS: Of the 19 patients treated with azathioprine for recurrent ileitis, 15 could be reevaluated by endoscopy or radiological examination. The therapy resulted in induction and maintenance of clinical remission in all 15 patients, at least 6 months after complete weaning of the corticosteroids. Complete macroscopic healing of the neoterminal ileum was observed in 6 of 15 patients, near-complete healing with only superficial erosions remaining in 5 of 15 patients, partial healing in 3 of 15 patients, and unchanged inflammatory lesions in 1 patient. CONCLUSIONS: It is concluded that azathioprine leads to mucosal healing in severe recurrent Crohn's ileitis and may be the treatment of choice in this indication.
Surgery for gastric remnant carcinoma following Billroth II gastrectomy.
Between January 1983 and December 1995, 31 patients with gastric remnant carcinoma were operated on 6-45 years after a Billroth II resection for peptic ulcer disease. Total gastrectomy with Roux-en-Y reconstruction was performed in all cases. In 16 patients (52%) extended resection with removal of one or more adjacent organs was necessary for oncological reasons. In this elderly population with a high incidence of pre-operative risk factors (55%), most tumours were classified as stage III or IV (45%). Although total gastrectomy should be the surgical option of first choice for gastric remnant carcinoma, it resulted in high levels of post-operative mortality and morbidity (13% and 35%, respectively), especially in patients with stage III and IV tumours who underwent resection of an adjacent organ. Despite extended surgery, if necessary, the recurrence rate after 'curative' surgery is high (8/20 patients) and the cumulative disease-free 5-year survival rate was 48%. Detection of the tumour at an earlier stage not only limits the extent of resection and lowers the complication rate, but also improves survival.
Tumoricidal activity of antiseptics with assessment of cell viability in mice with severe combined immunodeficiency.
Previously, we have assessed the efficacy of different cytotoxic agents on the viability of SW620 human colonic carcinoma cells in vitro. In this study, we have investigated the tumoricidal efficacy of some antiseptic agents on SW620 human colonic carcinoma cells which were subsequently inoculated into severe combined immunodeficient (SCID) mice. An inoculum of 5 x 10(6) cells suspended in 200 microliters buffer solution was found to be the minimum number of cells needed to result in tumour growth within 8 weeks after subcutaneous injection into SCID mice. The integrity of the cells was assessed in vitro with the trypan blue exclusion test after 30 min incubation in distilled water (DW), chloramine 0.5% in DW and polyvinyl pyrrolidone iodine (PVP-I) 0.01, 0.05, 0.1 and 5% in DW. DW and PVP-I 0.01% were not tumoricidal, neither in vitro nor in vivo. In contrast, PVP-I 5% and chloramine 0.5% 'killed' all or almost all tumour cells in vitro and prevented their growth in vivo. PVP-I 0.05 and 0.1% were less effective in vitro than 5%, but could prevent in vivo proliferation unless an adjustment of the residual number of viable tumour cells was performed. These data indicate the importance of the amount of the tumour inoculum and hence the need to use a maximally effective 'killing' agent.
A cost comparison of disposable vs reusable instruments in laparoscopic cholecystectomy.
BACKGROUND: This paper compares the costs of disposable and reusable instruments in laparoscopic cholecystectomy. METHODS: The instrument set considered includes those instruments that are available in both a reusable and disposable form. A market study within the Belgian market was performed in order to compare purchase prices. In addition, costs of cleaning, sterilization, wrapping, maintenance, repair, and disposal of waste were calculated. The effects of reusables and disposables were examined by means of a literature overview. RESULTS: It was calculated that the instrument cost per procedure of a full disposable set is 7.4-27.7 times higher than the cost per procedure with reusables. In comparison with disposables, modular systems ("semidisposable") and mixed use of disposables and reusables reduce costs, but still the cost per procedure remains higher than with reusables. A sensitivity analysis confirmed that these conclusions are robust to the model assumptions. In addition, the available evidence in the literature suggests that reusables do not compromise patient or staff safety. CONCLUSIONS: If reusables are used instead of disposables when performing a laparoscopic cholecystectomy, considerable savings can be achieved without compromising patient and staff safety.
Complications of CO2-laser endoscopic excision of deep endometriosis.
The complications during and following endoscopic excision of deep endometriosis were analysed. The data of 225 excisions performed in 212 women had been collected prospectively into a database immediately following surgery and during the follow-up visit. The data confirmed the association of severe pelvic pain and deep endometriosis, severe pelvic being the only indication for surgery in 67, 78 and 76% of women with type I (n = 99), type II (n = 55) and type III (n = 71) lesions respectively. They confirmed that type II and type III were the largest lesions and that they were found predominantly in revised American Fertility Society (AFS) class II. The duration of surgery decreased with expertise (P < 0.01), but increased when deeper or larger lesions were excised (P < 0.0001) and when cystic ovarian endometriosis was also present (P < 0.001). Excision was clinically judged to be complete in 94, 96 and 85% of women with type I, II or III lesions respectively. In order to achieve this, part of the bowel wall had to be resected in 6.3% and part of the posterior vaginal fornix in 13.6% of cases. This risk was associated mainly in type II or III lesions and with larger lesions (P = 0.001). This was not considered as a complication, since all lesions could be repaired endoscopically and since follow-up was uneventful. Complications were one ureter lesion and seven late bowel perforations with periotonitis. Our data did not permit the evaluation as to whether medical pretreatment could improve completeness of surgery or decrease the risk. They revealed, however, that in six of seven women with type III lesions--in whom excision was judged to be complete--no pretreatment had been given and that luteinizing hormone releasing hormone (LHRH) agonist treatment decreased the volume of type II lesions (P = 0.04). In conclusion, complete endoscopic excision could be performed in over 90% of women with deep endometriosis, but required bowel surgery in over 6% of cases. Ureter lesions were rare, but postoperative bowel perforations with periotonitis occurred in 2-3% of cases. Medical pretreatment is advocated since LHRH agonist treatment was shown to shrink the deep endometriotic lesion.
Comparative study of classical, colorimetric and immunologic staining methods for the assessment of tumor cell viability.
The trypan blue exclusion test, the MTT test and an immunostaining test for apoptosis were performed before and after incubation of SW620 human colonic carcinoma cells with different cytotoxic agents (CTAs) in order to assess tumor cell viability and CTA efficacy in vitro. A modified MTT test using light microscopy was also performed. A good correlation was found between the trypan blue assay and the MTT test, as determined by spectrophotometry. There was no 'overestimation' of cell viability as measured by the trypan blue test. The monitoring of formazan formation by light microscopy was feasible, but not very reliable since it did not show a good correlation with findings determined by spectrophotometry. The apoptosis test failed to show good correlation with other tests. Distilled water had no relevant cytotoxic effect, while chlorhexidine cetrimide (HAC 3.5%), chloramine 0.5% and polyvinylpyrrolidone iodine (PVP-I) > or = 0.05% damaged a large majority of cells. PVP-I at a concentration of > or = 5% was found to be the most effective CTA.
Technique and early results of videoscopic lumbar sympathectomy.
The authors describe their technique of videoscopic (VS) lumbar sympathectomy (LSE), compared to the open LSE. From 1992 to 1994, 21 open and 19 VS LSE were performed. The indication was reflex sympathetic dystrophy in 17 and arterial insufficiency in 23 patients. In the open LSE the mean duration of anaesthesia was 80 min (55-115) and of surgery 37 min (25-65). The length of the chain removed varied from 1 to 3 ganglia (6-7 cm). Complications were noted in 5 patients: 1 pneumonia, 2 superficial wound problems and 2 cases of postsympathectomy neuralgia. Hospital stay of patients with RSD varied from 2 to 5 days. Of the 19 attempts to perform a VS LSE 4 had to be converted to the open technique. The duration of anesthesia was 150 min (90-280) and of surgery 92 min (45-240). Lengths of chain removed varied from 1 to several ganglia (6-7 cm). A pneumoperitoneum was present in 10 procedures, but a Veress needle was placed in only 4 of these. Complications were present in 9 patients: 1 important subcutaneous emphysema, 1 severe costal pain, 2 neuralgia, 1 temporary psoas dysfunction, 1 haemorrhage from a lumbar vein with conversion to the open technique and 3 minor superficial wound problems. The hospital stay ranged from 2 to 5 days. This study suggests that the VS LSE has no benefit over the open technique as far as the operative and early results are concerned. Whether this technique avoids some of the late disadvantages of a lumbotomy remains to be seen.
Exfoliated tumour cells and locally recurrent colorectal cancer.
The presence of intraluminal viable exfoliated tumour cells has been demonstrated in patients with colorectal cancer. Several non-randomised studies found a significant reduction of the recurrence rate after the intraoperative luminal instillation of cytotoxic agents, as compared with "historical" patient series. Antiseptic solutions, e.g. sodium hypochlorite and povidone-iodine, were reported to be "cancericidal" for exfoliated cancer cells in vitro. A survey held among Belgian surgeons practising colorectal cancer surgery revealed that 78% of them never use any agent during surgery. Only a minority performs pre-resectional luminal instillation-mostly to treat the distal (low) anastomotic level: 14% in patients with rectal cancer and 7% in patients with colon cancer. About 8% of the surgeons only perform peritoneal/pelvic lavage at the end of the procedure. This is in strong contrast with surgical practice in the UK. It seems reasonable to advocate intra-operative pre-resectional bowel washouts with cytotoxic agents besides other measures to avoid recurrence, e.g. the no touch isolation technique with early division of the vascular supply, wide excision of the mesenterium, avoidance of iatrogenic tumour perforation, "en bloc" resection if adjacent organs are invaded, adjuvant radio- and chemotherapy.
Controlled trial of metronidazole treatment for prevention of Crohn's recurrence after ileal resection.
BACKGROUND/AIMS: New lesions recur within weeks to months after ileal resection and ileocolonic anastomosis for Crohn's ileitis. A double-blind controlled trial was performed using metronidazole to prevent recurrence after ileal resection. METHODS: Sixty patients who underwent curative ileal resection and primary anastomosis were included within 1 week after surgery. Thirty patients received metronidazole (20 mg/kg body wt) daily for 3 months, and 30 patients received placebo. Treatment was then discontinued. Nine patients dropped out during treatment, 7 in the metronidazole group and 2 in the placebo arm. RESULTS: At 12 weeks, 21 of 28 patients (75%) in the placebo group had recurrent lesions in the neoterminal ileum as compared with 12 of 23 patients (52%) in the metronidazole group (P = 0.09). The incidence of severe endoscopic recurrence was significantly reduced by metronidazole (3 of 23; 13%) as compared with placebo (12 of 28; 43%; P = 0.02). Patients in the metronidazole arm had more frequent side effects. Metronidazole therapy statistically reduced the clinical recurrence rates at 1 year (4% vs. 25%). Reductions at 2 years (26% vs. 43%) and 3 years (30% vs. 50%) were not significant. CONCLUSIONS: Metronidazole therapy for 3 months decreases the severity of early recurrence of Crohn's disease in the neoterminal ileum after resection and seems to delay symptomatic recurrence.
Contribution of PET in the diagnosis of recurrent colorectal cancer: comparison with conventional imaging.
The clinical value of total body PET with FDG was evaluated in 76 patients presenting with or suspected of recurrent local or distant colorectal cancer. PET results were compared to those of routine imaging (CT pelvis, CT/US liver and CXR). The accuracy of PET for local disease was 95% which was superior to CT-pelvis (accuracy 65%). PET accuracy for liver metastases (98%) compared favourably to CT/US-liver accuracy (93%). Unexpected extra-hepatic mestastases were detected by PET in 14 locations in 10 patients. Also, a primary breast cancer was found in one patient. The main value of PET appeared an improved staging of apparently resectable, local or distant recurrent disease. Thereby, a more adequate indication of major secondary surgery could be attained.
Radical versus local surgical treatment for rectum carcinoma. A variety of options?
Local excision has to be classified as either indeterminate or non curative from a surgical oncological point of view. It seems to be an acceptable procedure for well differentiated, exophytic/polypoid pT1 lesions of less than 3 cm in diameter, providing the resection margins are tumour-free. For all other lesions radical surgery is to be preferred, unless the patient is unfit for major surgery or refuses an eventual permanent colostomy. Complete local excision followed by radiation therapy may become a valuable alternative for well differentiated, small pT2 lesions, but results are too preliminary. If radical surgery is indicated, the distal clearance margin (to be measured in the fresh, unstretched specimen) may be reduced to 2 cm if taking more distal tissue would jeopardise the anal sphincter. The mesorectum should be completely cleared in patients with low- or mid-rectal cancer. A benefit of excision of the internal iliac nodes in rectal cancer below the peritoneal reflection has not been demonstrated. Low anterior resection is the operation of choice for carcinoma with its lower border above 8 cm from the anal verge. Complete, restorative rectum excision with colo-anal anastomosis (CAA) is the option for tumours with their lower border between 6 and 8 cm from the anal verge if an acceptable margin of distal clearance is obtained. Rectal cancer with its distal border below 6 cm usually requires abdominoperineal rectum excision, although restorative proctectomy with CAA may be a valuable alternative in selected patients with small, well or moderately differentiated tumours.
Clinical value of whole-body positron emission tomography with [18F]fluorodeoxyglucose in recurrent colorectal cancer.
To assess the clinical value of whole-body positron emission tomography (PET) with [18F]fluorodeoxyglucose (FDG) in recurrent colorectal cancer, 35 patients were studied: 15 had resectable liver metastases, one a resectable lung metastasis, eight resectable pelvic recurrence, eight a presacral mass with equivocal findings on imaging, and three increasing serum levels of carcinoembryonic antigen (CEA) without clinical or radiological signs of recurrent disease. PET affected management decisions in seven of 16 patients with metastatic disease. In one of eight patients with pelvic recurrence demonstrated by computed tomography (CT), PET detected unknown pulmonary metastases. In five of eight presacral masses with equivocal CT findings, PET was correct and unexpected distant metastases were detected in one of these patients. In two of three patients with increasing CEA levels and normal pelvic CT findings, pelvic recurrence was identified. Overall, whole-body PET affected management in 14 patients. PET is a valuable tool for staging local recurrence and metastatic disease.
Interleukin-6 and coagulation-fibrinolysis fluctuations after laparoscopic and conventional cholecystectomy.
This study assesses quantitatively the fluctuations of interleukin-6 (IL-6) and coagulation-fibrinolysis proteins in patients undergoing elective laparoscopic (n = 14) and conventional (n = 10) cholecystectomy. The patients in both groups were comparable in age and sex. Serum levels of interleukin-6, and plasma levels of fibrinogen, von Willebrand factor-antigen, tissue-type plasminogen activator-antigen, and plasminogen activator inhibitor-1 were determined for up to 48 h postoperatively. The postoperative changes of all parameters tested were comparable in both patient groups with a trend toward a higher interleukin-6 response at 8 h postincision (NS) and a trend toward a higher fibrinolysis inhibition (NS) after conventional cholecystectomy.
Restorative proctocolectomy in elective and emergency cases of ulcerative colitis.
A consecutive series of restorative proctocolectomy for ulcerative colitis was reviewed to determine whether an emergency restorative proctocolectomy procedure leads to a higher morbidity, more especially anastomotic leakage. Severity of illness and nature of surgery were divided in two categories: (1) no acute disease and elective surgery (18 patients), (2) acute disease requiring emergency surgery either immediately or within one week of admission (12 patients). Morbidity after elective surgery was 27% and after emergency surgery 66% (P < 0.06). Pouch-anal leakage occurred in 11% and 41% respectively (P = 0.08). Five risk factors significantly influenced the leak rate including preoperative white blood cell count > 10,000/microliter (P < 0.02), urgent nature of surgery (P < 0.02), the combination of leucocytosis and urgent nature of surgery (P = 0.02), the combination of leucocytosis and preoperative corticosteroid dose equivalent to > or = 200 mg hydrocortisone/24 h (P = 0.006), postoperative pelvic haematoma (P < 0.05). In conclusion, restorative proctocolectomy is contraindicated in emergency circumstances, especially in patients with signs of sepsis on a high corticosteroid dose. To reduce operative risk and number of procedures required, patients with relapsing ulcerative colitis should be referred for restorative proctocolectomy while being in remission.
Prevention of mucosal reperfusion damage after orthotopic small bowel autotransplantation in cats.
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Megadolichosigmoid in a young male with Aarskog syndrome.
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The costs and effects of open versus laparoscopic cholecystectomies.
The costs and effects of open versus laparoscopic cholecystectomies are compared, from the point of view of hospitals and patients, for a consecutive series of 47 patients undergoing a cholecystectomy in the University Hospital Gasthuisberg, in Belgium. For the patients the laparoscopic technique is superior, since effects are better and direct costs are lower than for the open technique. From a financial viewpoint, hospitals have to weigh the higher costs of the laparoscopic equipment against the lower variable costs due to the shorter postoperative length of stay. Total hospital costs would be lower in case all cholecystectomies were performed with the laparoscopic rather than with the open technique if at least 140 cholecystectomies are done annually with the electrocautery technique, or 300 procedures with laser. However, more recent data reveal that the operating time reduces with the number of laparoscopic procedures (learning effects), implying that the laparoscopic electrocautery procedure would already be the cheaper alternative if more than 70 cholecystectomies are done annually, if disposables are used (or if 50 procedures are done with re-usables). It can be concluded that, once sufficient experience with laparoscopy has been achieved, most hospitals could realise cost savings by switching, as much as is medically justified, to laparoscopic procedures. This will also hold for hospitals performing few cholecystectomies, as long as re-usables and electrocautery are used.