[Fulminating and subfulminating hepatitis. Surgical aspects in management and therapeutic prospects].
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Animals↗
Biomedical subjects
K Boudjema
Publications and source records attributed to K Boudjema.
Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Française de Chirurgie.
BACKGROUND: Five-year survival rates after resection of liver metastases from colorectal carcinoma are close to 25%. Recurrences occur in two-thirds of the patients after surgery. Selection of patients likely to benefit from surgery remains controversial and subjective. METHODS: Data from 1568 patients with resected liver metastases from colorectal carcinoma were collected. The prognostic value of different factors was studied through uni- and multivariate analyses. A scoring system was developed including the most relevant factors. RESULTS: Two- and 5-year survival rates were 64% and 28%, respectively, and were affected by: age; size of largest metastasis or CEA level; stage of the primary tumor; disease free interval; number of liver nodules; and resection margin. Giving one point to each factor, the population was divided into three risk groups three risk groups with different 2-year survival rates: 0-2 (79%), 3-4 (60%), 5-7 (43%). CONCLUSIONS: A simple prognostic scoring system was proposed to evaluate the chances for cure of patients after resection of liver metastases from colorectal carcinoma. The comparison between expected survival and estimated operative risk can help determine on an objective basis whether surgery is worthwhile. This system needs further prospective validation.
Aged↗
Auxiliary liver transplantation: regeneration of the native liver and outcome in 30 patients with fulminant hepatic failure--a multicenter European study.
Auxiliary liver transplantation (LT) is a special procedure of LT which could be proposed to patients with fulminant hepatic failure (FHF) and has for aim that complete regeneration of the native liver (NL) left in place will allow the graft recipient to resume normal liver function after allograft withdrawal. We report 30 cases of auxiliary LT performed for FHF in 12 European centers. Twenty-five of 30 patients were younger than 50 years. The cause of FHF was hepatitis A virus (HAV) in 4 patients, hepatitis B virus (HBV) in 7, paracetamol overdose in 5, ecstasy in 2, hepatotoxic drugs in 4, autoimmune hepatitis in 2, liver lesions of preeclampsia in 1 and unknown in 5. A postoperative, both clinical and histological follow-up of more than 3 weeks was obtained in 22 patients, enabling us to look for indicators predictive of NL regeneration and outcome. Histological changes observed in the NL included complete regeneration in 68%, incomplete regeneration with obvious fibrous sequelae in 14% and severe liver fibrosis or cirrhosis in 18%, of the 22 patients studied. The percentage and distribution of necrosis observed in tissue samples of the NL at the time of transplantation was not related to the final outcome. Complete NL regeneration was observed in 15 patients, out of whom 14 were younger than 40 years. Patients with complete regeneration were mainly affected by FHF due to HAV, HBV, or paracetamol overdose. After a follow-up of 18/11 (mean/median) months (range, 3 to 67 months), 19 of the 30 patients (63%) survived and 13 of them (68%), i.e., 43% of the 30 patients, had resumed normal NL function, with interrupted immunosuppression, the ultimate goal of emergency auxiliary LT. We conclude that, in patients with FHF, auxiliary LT is a procedure feasible in a number of centers and is associated with a complete regeneration capability of the NL in a majority of survivors, especially in those younger than 40 years. Confirmation of these encouraging preliminary results by large-scale prospective studies is required.
Adolescent↗
Liver grafts can be preserved overnight.
The introduction of University of Wisconsin solution has made liver transplantation a semi-elective procedure. However, many studies have suggested that cold storage must not exceed 12 hours to avoid ischemic-type biliary complications, to reduce the incidence of primary nonfunction and to improve graft and patient survival. The aim of this study was to compare the function of livers transplanted as soon as possible after the liver was harvested and those preserved overnight. Over a 42-month period, we studied 133 elective orthotopic liver transplantation procedures. When cold ischemia started after 6 PM, patients underwent transplantation the following morning (group A), whereas the remainder underwent transplantation immediately (group B). Cold ischemia lasted 13.7 hours and 9.5 hours in groups A and B, respectively (P < .001). The two groups were comparable in terms of initial and late biochemical liver function, the rates of primary nonfunction (6.5% in group A, 6.8% in group B), acute rejection (45.6% in group A, 45.7% in group B), and vascular and infectious complications. No ischemic-type biliary complications were observed. Graft and patient survival were similar in both groups (72.4% v 75.4% and 72.9% v 75.8% in groups A and B, respectively). These results suggest that having taken a cut off at 6 PM to divide the groups into those that underwent transplantation consecutively and those deferred to the morning, the difference between the two groups in terms of storage is relatively modest. Elective liver transplantation can be performed after overnight graft storage without increasing short-term or long-term morbidity or mortality rates.
Adolescent↗
[Benefits and limitations of pancreas transplantation in insulin-dependent diabetics: a study apropos of 26 patients].
From November 1990 to March 1995, 26 simultaneous pancreas-kidney (SPK) transplants were carried out. The recipients were uremic type I diabetic patients. After the first year of transplantation, patient survival was 96% and pancreas and kidney survival was 69% and 84%, respectively. The pancreas transplant failure was due to veinous thrombosis (two cases), and to graft rejection (71%). The most common urologic complications of bladder drainage were urethritis (61%), bicarbonate loss (42%) and urinary tract infections (100%). Fasting blood glucose (0.91 +/- 0.1 g/L), hemoglobin A1C (5.3 +/- 0.4%) and lipidic profile were found to be normal among diabetic recipients whose grafts had been functioning for 1 year. The insulin secretion of type I diabetic patients with SPK transplants (n = 13), and six non diabetic patients with kidney transplants was assessed by oral glucose tolerance tests. Only the patients with SPK transplants presented late hyperinsulinemia at 120 minutes. The quality of life for both type I diabetic patients after SPK transplants and diabetics treated by insulinotherapy (n = 6), was studied. After transplantation, the quality of life improved only because of insulin independence. In spite of chirurgical and urologic complications, pancreas transplantation in type I diabetic patients improves both metabolic control and quality of life.
Adult↗
Comparison of resection, liver transplantation and transcatheter oily chemoembolization in the treatment of hepatocellular carcinoma.
BACKGROUND/AIMS: Resection and liver transplantation are currently considered as the most useful treatments for hepatocellular carcinoma. However, transcatheter oily chemoembolization may be favourably compared with these two surgical treatments in patients with anatomically operable tumors. METHODS: Between 1985 and 1991, 122 patients with an Okuda stage I tumor were hospitalized in two French hospitals. Among these patients, 33 remained untreated, 42 were treated by transcatheter oily chemoembolization, 30 by resection and 17 by liver transplantation. The four groups were closely comparable except for age, the patients in the two surgical groups being significantly younger. Moreover, the frequency of pTNM II tumor was significantly higher in the resection group. RESULTS: The 5-year probability of survival was close to 45% in each of the three treated groups and was significantly higher than in the untreated group (0% at 4 years, p < 0.0001). The probability of cancer recurrence and/or metastatic dissemination was lower after transcatheter oily chemoembolization than after surgery. CONCLUSION: Thus, transcatheter oily chemoembolization seems comparable at 5 years with resection or transplantation for the treatment of resectable hepatocellular carcinoma.
Aged↗
Extracorporeal immunoadsorption of xenoreactive natural antibodies in the pig/rhesus model: comparison of three methods.
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Animals↗
[Technical progress in liver transplantation].
Over the last decade, liver transplantation has become the treatment of choice of end stage chronic liver diseases and acute hepatic failure. However, once this surgical technique was mastered, widespread application of liver transplantation revealed its Achilles' heel: complicated surgery especially with the need for veno-venous bypass, limited surgery because of graft scarcity, excessively radical surgery in case of liver transplantation for acute and potentialy reversible liver failure. Improved techniques were necessary to meet these new requirements generated by the success of liver transplantation. We present alternative techniques to the veno-venous by-pass, techniques of reduced-size and split liver grafts, liver transplantation from living related donor and auxiliary liver transplantation.
Humans↗
[Evaluation of a new technique of extracorporeal perfusion of the swine liver on a swine-primate model].
With the increasing success of liver transplantation there is an urgent need for developing an artificial liver support system to be used in patients with liver failure. An extracorporeal porcine liver perfusion machine was successfully tested in animals with experimental liver failure. Livers were flushed, removed from 35 kg pigs and placed in a heated sterile cassette. The portal vein and the hepatic artery of the graft were connected to the arterial system of the animals. The perfusion pressure of the hepatic artery was regulated via a pressure-flow computerized feed-back device. The venous flow was reinfused from the hepatic veins of the graft to the jugular vein of the animals. The experimental work consisted in two steps: 1. evaluation of clinical and biological consequences of liver perfusion in healthy animals (Group A = pigs, n = 3; group B = primates, n = 3); 2. evaluation of the efficiency of the liver perfusion in animals with ischemic liver failure (Groupe D = pigs, n = 6). The control group (Group C = pigs, n = 7) consisted of pigs with ischemic liver failure without hepatic support. No major clinical or biological adverse effects are reported in groups A and B excepted a thrombocytmia and a marked increase in serum transaminases levels in group B. Liver function as assessed by the bile flow was good in both groups. Comatose pigs with ischemic hepatic failure (group D) recovered a subnormal neurological status in five out of six cases. Serum ammoniemia level were significantly decreased (from 1076 +/- 163 to 255 +/- 32 umol/l). A decrease in serum bilirubine levels and an improvement in the coagulation profile were observed in the perfused animals. Pigs and primates tolerated the perfusion procedure well and beneficial effects were observed in perfused pigs with experimental liver failure.
Animals↗
[Surgical treatment of synchronous hepatic metastases of colorectal cancers. Simultaneous or delayed resection?].
The surgical strategy for resectable synchronous hepatic metastases of colorectal cancer remains controversial. The retrospective analysis of our series of resectable synchronous hepatic metastases focused on the percentage of simultaneous resections, the circumstances, the indications and the results of the one-step procedure compared to the two-step strategy. From January 1, 1982 to December 31, 1995, 129 patients were operated on for resection of hepatic metastases of colorectal cancer. Forty one patients (32%) presented with synchronous hepatic metastases, 20 of whom (49%) underwent simultaneous resection of the primary tumor and the hepatic metastases (simultaneous resection group: SR). For the other 21 patients (51%), the hepatic resection was delayed for a mean interval of 5.2 +/- 4.2 months (delayed resection group: DR). The mean age of the 2 groups was not significantly different (54 years versus 58 years). When the primary tumor was located on the ascending colon, the hepatic excision was performed simultaneously in 9 out of ten cases. The need for blood transfusion and the volume required were not significantly different between the two groups. The length of each surgical operation was comparable between the two groups (331 +/- 76 minutes SR vs 330 +/- 88 minutes DR). Postoperative complications were observed in 20% of patients in the SR group and 10% of patients in the DR group (no significative difference). There was no postoperative mortality in either group. Survival was 83%, 44% and 37% at 1, 2 and 3 years respectively in the SR group and 79%, 59% and 49% in the DR group, with no significant difference between the groups. These results show that simultaneous resection of the primary tumor and the hepatic metastases did not increase either morbidity or mortality in our study, and that it should be proposed especially to patients presenting with a primary tumor of the ascending colon with metastases resectable by means of a minor hepatectomy.
Actuarial Analysis↗
Technical aspects of orthotopic liver transplantation.
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Anastomosis, Surgical↗
Auxiliary liver transplantation for fulminant and subfulminant hepatic failure.
We report the first series of 9 auxiliary liver transplantations performed as a bridge to recovery in 8 patients with fulminant and subfulminant hepatic failure. Hepatic failure was due to hepatitis A virus (n = 3), hepatitis B virus (n = 1), hepatotoxic drugs (n = 2), autoimmune disease (n = 1), or it was of unknown origin (n = 1). The donor liver was reduced to a left lobe (n = 2), a left liver (n = 4), or a right liver (n = 3), and was implanted in an orthotopic position beside the native liver after it was resected by a left or a right hepatectomy. Conventional immunosuppression was used to prevent rejection. Six patients regained normal consciousness within 2 weeks, without any sequelae. Two patients had persisting encephalopathy due to graft initial dysfunction, one of whom showed portal vein thrombosis, which was successfully cleared. The other one showed hepatic vein stenosis and was retransplanted at day 15. Five of eight patients had to be reoperated because of a surgical complication. Five patients showed rapid regeneration of their native liver, but one died at day 45 from severe herpes virus broncholitis. The auxiliary grafts were removed (n = 3) or left to atrophy by tapering immunosuppression (n = 1). One patient developed cirrhosis of the native liver and died of infectious complications at day 42. The native livers of the two remaining patients are still atrophic, one at 4 months and one at 1 month posttransplant. Finally, 6 of 8 patients are alive with a follow-up of 1 to 17 months. Four of them have permanently stopped their immunosuppressive therapy. Our experience demonstrates that auxiliary orthotopic liver transplantation (1) is feasible in children and adults, using either a left or a right liver graft, (2) is efficient in providing adequate liver function, and (3) gives a real chance to the native liver to regenerate, offering these patients a future free of immunosuppression.
Adolescent↗
Effects of platelet-activating factor antagonist on preservation/reperfusion injury of the graft in porcine orthotopic liver transplantation.
To investigate the role of platelet-activating factor (PAF) in the preservation/reperfusion injury of the liver graft, the effect of treatment with a potent PAF antagonist (E5880) was evaluated in a pig orthotopic liver transplantation model. The graft liver was flushed out and preserved for 8 hr at 4 degrees C using a simplified University of Wisconsin solution. The PAF antagonist was administered into the University of Wisconsin solution (1 mg/L), into the rinsing solution (1 mg/L), and to a recipient pig (0.3 mg/kg d.i.v.) in group 1. The PAF antagonist was not given in the control group (group 2). Postoperative survival of more than 12 hr was 100% (9/9) in group 1 and 56% (5/9) in group 2 (P < 0.05). At 12 hr after reperfusion of the graft (RPF), the arterial ketone body ratio (acetoacetate to 3-hydroxybutyrate) increased to 1.54 +/- 0.15 (mean +/- SEM) in group 1, compared with 0.95 +/- 0.09 (P < 0.05) in group 2. In group 2, blood leukocyte count decreased to 8.3 +/- 0.9 (x 10(3)/microliters) at 2 hr after RPF, in contrast to a slight increase in group 1 (14.3 +/- 1.8 x 10(3)/microliter, P < 0.01). At 4 hr after RPF, glutamic oxaloacetic transaminase (461 +/- 59 vs. 712 +/- 97 U/L, P < 0.05), glutamic pyruvic transaminase (65 +/- 4 vs. 82 +/- 5 U/L, P < 0.05), and the lactate level (6.2 +/- 1.1 vs. 9.4 +/- 1.0 mmol/L, P < 0.05) in arterial blood were significantly lower in group 1 than in group 2. Light and electron microscopic study at 1 hr after RPF showed neutrophil sludging in the sinusoids and sinusoidal endothelial cell damage in group 2, while these findings were attenuated in group 1. It is suggested that PAF plays a key role in microcirculatory disturbance of the liver graft manifested on reperfusion, and that the treatment with E5880 has a protective effect against preservation/reperfusion injury of the graft in liver transplantation.
Adenosine↗
Superselective endo-vascular treatment of renal vascular lesions.
Embolization with platinum micro-coils delivered through the Tracker-18 micro-catheter was performed in 6 patients when peripheral selective catheterization with standard angiographic catheters was not possible. The patients had a total of 7 peripheral renal vascular lesions (3 arteriovenous fistulas, 2 false aneurysms, 1 direct vascular trauma and 1 arteriovenous malformation). In all patients we initially used platinum micro-coils as the embolic agent. Two patients required repeat embolization with glue. Endo-vascular treatment was technically successful in all cases and no complications were encountered. There was no renal parenchyma infarction in 3 patients and small peripheral infarctions (10 to 15% of the renal parenchyma) occurred in 3. Super selective endo-vascular treatment with a variable stiffness catheter is safe and useful technique when classical methods of embolization are not possible.
Adult↗
Protective effects of N-acetylcysteine on hypothermic ischemia-reperfusion injury of rat liver.
We investigated whether intraportal injection of 150 mg/kg N-acetylcysteine (NAC) into rats reduced hepatic ischemia-reperfusion injury after 48 hours of cold storage and 2 hours of reperfusion. The organ was isolated and perfused to evaluate liver function. The control group received an intraportal injection of 5% dextrose. NAC increased L-cysteine concentrations 15 minutes after injection (1.29 +/- 0.11 mumol/g vs. 2.68 +/- 0.4 mumol/g, P < .05). However, neither treatment modified glutathione liver concentrations relative to preinjection values. After 48 hours of cold storage and 2 hours of reperfusion, livers from NAC-treated rats produced larger amounts of bile than those in the control group (5.04 +/- 1.92 vs. 0.72 +/- 0.37 microL/g liver; P < .05), and showed a significant reduction in liver injury, as indicated by reduced release of lactate dehydrogenase (679.4 +/- 174.4 vs. 1891.3 +/- 268.3 IU/L/g; P < .01), aspartate transaminase (AST) (13.94 +/- 3.5 vs. 38.75 IU/L/g; P < .01), alanine transaminase ALT) (14.92 +/- 4.09 vs. 45.91 +/- 10.58 IU/L/g; P < .05), and acid phosphatase, a marker of Kupffer cell injury (344.4 +/- 89.6 vs. 927.3 +/- 150.8 IU/L/g; P < .01) in the perfusate. Reduced glutathione concentrations in the perfusate were similar in the two groups (805 +/- 69 vs. 798 +/- 252 nmol/L/g), whereas oxidized glutathione (GSSG) concentrations were higher in the control group (967 +/- 137 vs. 525 +/- 126 nmol/L/g; P < .05). Reduced glutathione (GSH) concentrations in liver tissue collected at the end of perfusion were significantly higher in the NAC group (7.3 +/- 0.9 vs. 4.1 +/- 1.0 mumol/g; P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)
Acetylcysteine↗
Platelet activating factor antagonist has a protective effect on preservation/reperfusion injury of the graft in pig liver transplantation.
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Alanine Transaminase↗
[Islet of Langerhans transplantation].
Islet of Langerhans transplantation is considered to be the ideal treatment for type I insulin-dependent diabetes. The permanent and adapted insulin secretion obtained by this method ensures prevention or even regression of the degenerative lesions which now constitute the severity of this frequent disease. Islets of Langerhans can be isolated from human pancreas and implanted freely in the liver or spleen. However, this source of grafts is limited and implantation of alloantigens requires the use of anti-rejection immunosuppressant therapy. The isolation of islets of Langerhans from porcine pancreas would represent an ideal solution to the shortage of human grafts, but the high immunoreactivity of xenoantigens prevents the possibility of free graft. For this reason, cell encapsulation systems in semipermeable and biocompatible membranes, at least theoretically able to ensure permanent tolerance of the cells, have been developed. The objective of this review is to inform general surgeons about the state of progress of studies in an area considered to be the first step of a promising therapeutic era in which they will be required to participate: that of cell therapy.
Humans↗
Evaluation of efficacy of liver transplantation in alcoholic cirrhosis by a case-control study and simulated controls.
To assess the efficacy of liver transplantation in patients with alcoholic cirrhosis, we compared 2-year survival of 169 liver transplantation patients in 12 French centres with survival of two control groups treated conservatively. The matched group was 169 patients of similar age, cirrhosis severity, and bleeding history; the simulated group was 169 patients whose theoretical survival was determined in a cohort of 797 patients with alcoholic cirrhosis. The probability of survival to 2 years in transplanted patients was 73 (95% confidence interval 67-79%) versus 67% (59-75) in the matched and 67% (63-71) in simulated controls. When prognostic factors were taken into account, transplantation was associated with survival (r = 0.527; p = 0.069). Patients with severe liver disease (high-risk group) benefited most for 2-year survival: 64% (42-86) vs 41% (23-59) in the matched and 23% (19-27) in the simulated control groups (p < 0.01). There was no difference for patients at low and at medium risk. Liver transplantation increases the 2-year survival of patients with severe alcoholic cirrhosis. In patients with less severe disease, further studies should be done by non-randomised controlled studies with longer follow-up or by randomised trials.
Adult↗