Long-term results of the Lyons R90-01 randomized trial of preoperative radiotherapy with delayed surgery and its effect on sphincter-saving surgery in rectal cancer.
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Anal Canal↗
Biomedical subjects
M Adham
Publications and source records attributed to M Adham.
[Intussusception of the small intestine due to Peutz-Jeghers syndrome: a case report and review of the literature].
One case of small bowel's intussuception has been found in one patient with abdominal pains. Since 13 years this patient has a Peutz-Jeghers syndrome. A resection of the small bowel has been performed followed by total intraoperative enteroscopy. Besides small bowel, Peutz-Jeghers syndrome can affect many organs with an increased risk for cancer for patients affected by this genetic disease.
Humans↗
Early activation of hepatic stellate cells and perisinusoidal extracellular matrix changes during ex vivo pig liver perfusion.
In previous works, we observed during liver transplantation procedure, the early activation of hepatic stellate cells (HSC) which acquire alpha-smooth muscle (SM) actin expression. In this study, we evaluated changes in HSC and in perisinusoidal extracellular matrix during ex vivo pig liver perfusion. Under general anesthesia, pig livers were flushed and removed, and then perfused ex vivo for 6 h with homologous blood. Liver biopsies were taken before and after washout, at 5 min perfusion, and then hourly. Tissues were processed for immunohistochemistry, immunofluorescence, confocal microscopy, in situ hybridization and electron microscopy. Before and after liver washout, alpha-SM actin was present in vessel walls but in very few lobular HSC. After 1 h perfusion, a strong reactivity for alpha-SM actin was present in HSC, particularly along dilated sinusoids. At the ultrastructural level, numerous microfilament bundles appeared in HSC cytoplasmic processes. During perfusion, type I and type IV collagens, type III procollagen, and fibronectin acquired a looser organisation in relation with the enlargement of perisinusoidal spaces; laminin appeared in perisinusoidal spaces around portal areas and fibrillin deposits increased. In situ hybridization studies showed an increase of the type I procollagen mRNA expression mainly in portal tracts and septa. Ex vivo liver perfusion induces: 1) an early activation of HSC which acquire the expression of alpha-SM actin, and 2) significant changes in the perisinusoidal extracellular matrix. These results are compatible with the view that HSC function as liver specific pericytes participating in the regulation of sinusoidal blood pressure.
Actin Cytoskeleton↗
Combined chemotherapy and radiotherapy followed by surgery in the treatment of patients with squamous cell carcinoma of the esophagus.
BACKGROUND: Surgery remains the treatment of choice for patients with esophageal squamous cell carcinoma (SCC), but survival rates have not improved over the past decades. The objective of this study was to evaluate the effect of multimodal therapy on resectability, on the overall and on disease free survival (DFS) rates, and on the laryngeal resection rate. METHODS: Fifty-five patients (49 men and 6 women) with a mean age of 58 +/- 8 years underwent combined modality treatment for esophageal SCC. The tumor location was in the upper one-third of the esophagus in 19 patients, the middle one-third in 22 patients, the lower one-third in 9 patients, and the upper and lower one-thirds in 5 patients. The intent of combined therapy was curative in 87.3% of patients and palliative in 12.7% of patients. Neoadjuvant treatment consisted of two courses of 5-fluorouracil and cisplatin on Days 1-5 and Days 21-25. Radiotherapy was commenced on Day 21 and consisted of 36 grays delivered in 12 fractions over 17 days. Surgery was performed on Day 60. RESULTS: Full neoadjuvant treatment was possible in 67.3% of patients and was uneventful in 56. 4% of patients. The resection rate was 96.4% (complete macroscopic resection with histologic clear margins [R0], 83.6%; complete macroscopic resection with microscopic disease at the resection margin [R1], 1.8%; and macroscopic residual disease [R2], 10.9%). The operative mortality rate was 0%, whereas the hospital mortality was 7.3%. Twenty-three patients had a complete macroscopic response, 12 of whom (21.8%) had a complete histopathologic response. The tumor stages according to the American Joint Committee on Cancer staging system were pT0N0 in 12 patients, Stage 0 in 8 patients, Stage IIa in 6 patients, Stage IIb in 6 patients, Stage III in 8 patients, and Stage IV in 13 patients. Laryngeal preservation was achieved in 8 of 12 patients in whom total pharyngolaryngoesophagectomy initially was indicated because of tumor response and an R0 resection. The overall survival rates at 1 year, 3 years, and 5 years were 61%, 39%, and 33%, respectively, and the DFS rates were 49%, 32%, and 29%, respectively. The respective survival rates for responders were 82%, 58%, and 53%, and the DFS rates were 68%, 54%, and 48%. CONCLUSIONS: Neoadjuvant treatment is tolerated well by most patients. Combination therapy increases the resectability rate and facilitates laryngeal preservation. Significant improvements in the actuarial survival rate and the DFS rate were observed in the group of patients who achieved partial and complete responses.
Adult↗
Laparoscopic gastrostomy.
Although percutaneous endoscopic gastrostomy (PEG) has become a common technique for the placement of gastrostomy tubes, gastrostomy can be performed via the laparoscopic approach with minimal trauma or by using a percutaneous gastrostomy kit. In this report, we describe two procedures for laparoscopic gastrostomy using standard instruments. Standard laparoscopic techniques are used to create a pneumoperitoneum. In the first method, three transparieto-transgastric U stitches are placed to surround the site selected for the gastrostomy. A Foley catheter is inserted through the abdominal and gastric opening, then tied to the stomach with a pursestring suture. Traction on the balloon catheter brings the stomach to the anterior abdominal wall, where the three U stitches can be tied. In the second method, a 9-cm vascularized isoperistaltic gastric tube is made on the greater curvature using an endoscopic linear cutter and preserving the gastro-omental vessels. This gastric tube is then brought out through the anterior abdominal wall via a trocar orifice, opened, and fixed to the skin as for standard ostomy. Laparoscopic gastrostomy is a straightforward procedure that reduces postoperative pain and ileus. It obviates the need for a laparotomy while creating an adequate gastrostomy. Postoperative recovery is prompt, with rapid return of intestinal function and early discharge from the hospital. It not only represents an alternative to PEG when this route is not suitable or after failure of the procedure, but can also be widely used for patients as a first choice.
Abdominal Muscles↗
Laparoscopic resection of a proximal splenic artery aneurysm.
The usual treatment for splenic artery aneurysm is resection under laparotomy. In recent years, the laparoscopic approach has consisted of ligation without resection. More recently,laparoscopic resection was reported by the Cleveland Clinic. In this paper, we describe the technique used in the laparoscopic resection of our first case of laparoscopic resection of splenic artery aneurysm (SAA). The patient was a young woman with a 12-mm SAA discovered on systematic abdominal ultrasound. The laparoscopic procedure was done successfully, and the aneurysm was resected using an ultrasonic dissector. The postoperative course was uneventful, and the patient was discharged on the 3rd postoperative day. Pathological examination revealed the atherosclerotic origin of the aneurysm. The patient is doing well 12 months after surgery, with normal splanchnic Doppler ultrasound. This procedure offers a one-step definitive cure via a minimally invasive surgical procedure.
Adult↗
Functional results of delayed coloanal anastomosis after preoperative radiotherapy for lower third rectal cancer.
BACKGROUND: The aim of this study was to assess functional outcomes of patients who had a delayed coloanal anastomosis for a lower third rectal cancer after preoperative radiotherapy. STUDY DESIGN: From January 1988 to December 1997, 35 patients with an adenocarcinoma of the lower third of the rectum received preoperative radiotherapy (45Gy) followed by a rectal resection, combining an abdominal and transanal approach. Colorectal resection was performed about 32 days after the end of the radiotherapy. The distal colon stump was pulled through the anal canal. On postoperative day 5 the colonic stump was resected and a direct coloanal anastomosis performed without colostomia diversion. RESULTS: There was no mortality. There was no leakage. One patient had a pelvic abscess. One patient had a necrosis of the left colon requiring reoperation. Another delayed coloanal anastomosis could be performed. Median followup was 43 months (range 6 to 113 months). Functional results were evaluated with a new scoring system including 13 items. Function was considered good in 59% and 70% at 1 and 2 years, respectively. CONCLUSIONS: This new procedure is a safe and effective sphincter-preserving operation that avoids a diverting stoma for patients with rectal cancer of the lower third of the rectum. This technique is well adapted for patients receiving preoperative radiotherapy, with low local morbidity and good functional results. Further adaptation could be imagined for a coelioscopic approach.
Adenocarcinoma↗
Hemodynamic profiles during piggyback liver grafts using arterial or portal revascularization.
BACKGROUND: The order of revascularization in human liver grafts is still discussed. This study tries to answer this question in terms of hemodynamic data. STUDY DESIGN: Fifty-nine patients were randomized in this study to compare hemodynamic data just before and 15 minutes after revascularization of liver grafts in relation to first hepatic artery (n = 29) or first portal vein (n = 30) revascularization procedure. RESULTS: Hemodynamic variations were significantly greater in the portal vein group than in the hepatic artery group in terms of mean arterial pressure, cardiac index, central venous pressure, pulmonary capillary pressure, and systemic vascular resistance. The latter decreased from 741.8 +/- 390.3 to 659.9 +/- 411.1 dynes/ cm5 (NS) in the hepatic artery group versus 807.7 +/-336.7 to 439.7 +/- 215 dynes/cm5 (p < 0.05) in the portal vein group. Clinical results and postoperative complications, graft characteristics, patient survival, and graft survival were not significantly different between the groups. CONCLUSIONS: Initial arterial revascularization of the liver graft leads to a more stable hemodynamic profile during revascularization of the liver graft after vascular unclamping. This technique is always feasible and has become our reference procedure.
Anastomosis, Surgical↗
Anti-hepatitis C virus core IgM antibodies correlate with hepatitis C recurrence and its severity in liver transplant patients.
BACKGROUND: The significance of immunoglobulin (Ig) M antibody to hepatitis C virus (HCV) core antigen was studied in 60 patients with HCV infection after orthotopic liver transplantation (OLT) diagnosed by polymerase chain reaction. METHODS: Patients were followed up for a mean of 28 months after transplantation. Sera collected three months before transplantation, and one and 12 months after transplantation were analysed for anti-HCV core IgM (HCV-IgM EIA 2.0 assay). After OLT protocol biopsies, procedures were performed routinely every six months. Semiquantitative histopathological assessment of allograft hepatitis was performed using Knodell's score. The results were correlated with clinical features, liver histology findings, and virological features, such as genotype and viraemic levels assessed by a branched DNA assay. RESULTS: One year after liver transplantation, 29/60 (48%) patients had chronic hepatitis on graft biopsy. The presence of anti-HCV core IgM one month (p=0.004) and 12 months (p=0.003) after OLT was positively correlated with recurrence of chronic hepatitis. The positive predictive value of anti-HCV core IgM detected one month after transplantation was 0.88. A significant relationship was observed between severity of graft disease and presence of anti-HCV core IgM 12 months after transplantation. The mean Knodell score was 8.9 in anti-HCV core IgM positive patients compared with 3.6 in those who were anti-HCV core IgM negative (p=0.001). The presence of IgM anti-HCV did not correlate with serum HCV RNA level or HCV genotype. CONCLUSION: We confirm that the presence of anti-HCV core IgM after OLT is a marker of HCV induced graft damage. The recurrence and severity of HCV hepatitis in patients undergoing OLT for HCV cirrhosis is related to the presence of anti-HCV core IgM after liver transplantation. These findings have diagnostic relevance and confirm that measurement of IgM anti-HCV core may help to better monitor the treatment of HCV recurrence after transplantation.
Adult↗
[Barrett's esophagus and antireflux surgery: a study of a series of 26 patients].
STUDY AIM: The aim of this study was to report the results of a retrospective series of 26 patients with Barrett's esophagus treated by antireflux surgery. PATIENTS AND METHODS: From 1979 to 1998, 21 men and five women (mean age: 53 years) with histologically proven Barrett's esophagus underwent an antireflux procedure. The mean length of Barrett's epithelium was 5.9 cm for 19 patients (73.1%). Six patients (23.1%) had tongue lesions of Barrett's epithelium, and one (3.8%) had ectopic gastric mucosa. None of the patients had a preoperative esophageal biopsy that revealed high-grade dysplasia or carcinoma. Laparotomy was performed in 17 cases and laparoscopy in nine cases. Preoperative endoscopic local treatment with argon coagulation was performed in one patient. RESULTS: Clinical mean follow-up was 78 months and endoscopic mean follow-up was 59.3 months. No increase in the length of the Barrett's epithelium was observed. Seven patients (27%) had complete or partial regression (among them three patients with tongue lesions and one patient preoperatively treated by argon). No patients developed high-grade dysplasia or carcinoma. CONCLUSION: Regression of Barrett's esophagus is possible but not frequent and unpredictable after antireflux procedure. However, endoscopic and histological surveillance should be continued postoperatively.
Adult↗
[Oncologic and functional results of resections with direct delayed coloanal anastomosis in previously irradiated cancers of the lower rectum].
AIM OF THE STUDY: The aim of this study was to assess the oncology and functional outcome after preoperative radiotherapy and delayed coloanal anastomosis for cancers of the lower third of the rectum. PATIENTS AND METHODS: From January 1988 to December 1997, 35 patients received preoperative radiotherapy (45 Gy) followed by rectal resection through a combined abdominal and transanal approach. Thirty patients had preoperative tumor staging with endorectal ultrasonography: uT1N0 = 2, uT2N0 = 6, uT2N+ = 2, uT3N0 = 6, and uT3N+ = 14. Colorectal resection was performed on average 32 days after the conclusion of radiotherapy, and the distal colon stump was pulled through the anal canal. On postoperative day 5, the colonic stump was resected and a direct coloanal anastomosis performed. RESULTS: Pathological examination of the specimens revealed complete tumor sterilization in two cases, pT1N0 = 3, pT2N0 = 14, pT2N+ = 1, pT3N0 = 6, and pT3N+ = 9. There was no postoperative mortality and there was no leakage. One patient had a pelvic abscess, and another one had left colon necrosis which required re-operation. Median follow-up was 43 months (range 6-113). Two patients had locoregional recurrence, seven had distant metastasis, and 3 had both. Actuarial survival rate at 1, 3 and 5 years was 97%, 86%, and 72% respectively. The rate of local control at 5 years was 78%. Functional results were evaluated by a new scoring system. Function was considered good in 59 and 70% at 1 and 2 years respectively. CONCLUSION: This new procedure is a safe and effective sphincter-preserving operation that avoids a diverting stoma. It is well adapted for patients receiving preoperative radiotherapy, with low local morbidity and good functional results.
Adult↗
[Long-term results of 186 patients with large incisional abdominal wall hernia treated by intraperitoneal mesh].
Massive incisional abdominal wall hernias are frequent and difficult to repair, especially when they are large, multiply recurrent and when associated high with risk factors. We report the long-term results of 192 hernia repairs (in 186 patients) by non-resorbable mesh placed intraperitoneally and fixed by fascia stapler. We describe the details of the technique. There were no deaths. Early and late wound infections occurred in 11.7%, late occlusions in 6.3% and recurrence in 16%. Four percent of patients required removal of the mesh. The main caracteristic of this study was the long follow-up period (mean duration = 77 months). In view of the good results (70%), simplicity and quite execution of this technique, intraperitoneal mesh placement should be considered in the repair of large hernias when a prothesis is required.
Adolescent↗
[Mucocele on bypassed esophagus: two operated cases].
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Adult↗
[Extended venous ischemia of the small intestine caused by portal thrombosis. Value of diagnostic celioscopy and intestinal bi-exclusion (Thiry-Vella technique)].
Mesenteric venous thrombosis is a rare disease with no specific signs. It's major risk is intestinal ischaemia and necrosis. We report the case of a young women who presented with unexplained abdominal pain and subnormal abdominal ultrasound. The diagnosis was made on laparoscopic exploration which allowed anticoagulant therapy followed by proximal and distal divertingostomies of the ischemic bowel. Small bowel continuity was re-established after 3 month of total parenteral nutrition. The patients is doing well 1 year after surgery. She is still under anticoagulant therapy. The etiology found was a hypermegacaryocytosis as seen in myeloproliferative disease.
Adult↗
Results of orthotopic liver transplantation for liver cirrhosis in the presence of incidental and/or undetected hepatocellular carcinoma and tumour characteristics.
Orthotopic liver transplantation (OLT) for liver cirrhosis in the presence of hepatocellular carcinoma (HCC) is based on tumour number and size. The high incidence of undetected HCC before OLT has been reported previously. The object of this work to report the results of OLT for liver cirrhosis in the presence of incidental and/or undetected HCC and tumour characteristics. From 1985 to 1996, 334 patients received OLT. Two groups of patients were studied; group 1 (G1) where HCC was diagnosed on radiological examination before OLT (n = 13, mean age 53.8 +/- 8.1 years), and group 2 (G2), where HCC was diagnosed on pathological review (n = 13, mean age 53.3 +/- 6.1 years). Indications for OLT were (G1/G2) hepatitis C = 6/8, hepatitis B = 5/2, alcoholic = 2/3. There was no statistically significant difference in alpha-foetoprotein levels between both groups. Pathological review showed 26 and 30 HCC with a mean size of 1.6 +/- 0.8 and 1.6 +/- 1.2 cm (P > 0.05) in G1 and G2, respectively. Tumour stagings were (G1/G2) stage I = 6/2, stage II = 4/6, stage III = 2/3, stage IVa = 1/2. We had two (G2) hospital and three (G1) later mortalities; none had HCC recurrence. The other patients are alive and recurrence free. Reinforced immunosuppression related to acute or chronic rejection treatment was not associated with HCC recurrence. The 5-year actuarial survival rates were 76% for G1 and 85% for G2 (P > 0.05). Our study revealed that long-term survival can be achieved with liver transplantation in the presence of HCC in carefully selected patients.
Carcinoma, Hepatocellular↗
Influence of systematic echodoppler arterial survey on hepatic artery thrombosis after liver transplantation in adults.
Hepatic artery thrombosis after liver transplantation remains a major problem which may lead to graft loss and retransplantation. Hepatic artery diseases were compared in two matched groups of liver grafted patients. In Group I (67 patients), echodoppler examinations of the graft hepatic artery were carried out after clinical or biological abnormalities became evident. In Group II (85 patients), echodoppler examinations were systematically made during the follow-up at 2 weeks, 1, 3, 6, and 12 months after liver transplantation. In cases of an abnormal echodoppler examination, arteriography was carried out in order to confirm hepatic artery stenosis and to perform endoluminal angioplasty. In Group I, echodoppler examinations revealed no arterial blood flow in three cases and reduction of hepatic blood flow in two cases. Hepatic artery thromboses were always confirmed by angiography, in the latter two cases, a collateral arterial revascularization of the graft was developed. In this group, two retransplantations, one choledocojejunostomy, and four percutaneous radiological biliary drainages were necessary. In Group II, echodoppler results showing a resistive index below 0.5 and a systolic acceleration time above 0.08 s involved 13 arteriographies. Ten stenoses were diagnosed without any biological abnormalities. Nine endoluminal angioplasties were made without any complication. There was no recurrence of stenosis. One pseudoaneurysm of the femoral artery was cured by compression. The early and non-aggressive detection of hepatic artery stenoses after liver transplantation by echodoppler allows treatment by angioplasty in order to prevent hepatic artery thrombosis and reduce retransplantation.
Angioplasty↗
[Is pancreatectomy with resection of the retro-pancreatic vessels for cancer justified?].
AIM OF THE STUDY: Tumoural invasion of the retropancreatic vessels and particularly of the superior mesentericoportal vein confluence (SMPV) is often considered as a contraindication to resection of malignant tumours of the pancreas. The aim of this retrospective study is to report a series of 20 patients and to demonstrate that resection of the vessels supposed to be involved is justified when it is the only barrier to a complete tumoural resection. PATIENTS AND METHOD: Twenty patients, 11 men and nine women (mean age: 61.7 years) underwent a right (n = 14), left (n = 2) or total (n = 4) pancreatic resection for pancreatic adenocarcinoma (n = 19) or cystadenocarcinoma (n = 1) associated with partial resection of SMPV (n = 17), inferior vena cava (n = 1), right hepatic artery (n = 1) and common hepatic artery (n = 1). The veins were reconstructed in all cases by end to end anastomosis and the arteries by direct suture in one patient and venous or artery graft in two patients. RESULTS: Tumoural invasion was histologically present in the vascular wall in nine patients, in the perivascular area in six and negative in five. The in-hospital mortality was nil. One patient had an early venous thrombosis of the repaired SMPV which was reoperated and treated with success by desobstruction and venous graft. The 3-year actuarial survival rate was 16%. CONCLUSION: Segmental venous resection of the SMPV confluence can be performed safely. Localised invasion of the vascular wall, considered as the only obstacle for a complete tumoural resection, is not associated with a poor prognosis. In case of tight adhesions between tumour and SMPV (inflammatory or tumoural) the venous resection may be included in a deliberate surgical strategy. On the other hand, total obstruction of SMPV, extrapancreatic tumoural extension, tumoural invasion of superior mesenteric artery or coeliac trunk are contraindications to pancreatic resection.
Actuarial Analysis↗
Rescue FK506 therapy for acute rejection and early chronic rejection after liver transplantation: report of 14 cases.
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Acute Disease↗