[Surgical treatment of severe ulcerous hemorrhages: predictive factors of operative mortality]

OBJECTIVES

Multivariate analysis of operative mortality in patients with bleeding peptic ulcer.

METHODS

Seventy-eight consecutive patients, who underwent emergency surgical treatment for bleeding peptic ulcer were reviewed retrospectively. There were 49 males and 29 females, with a mean age of 64.3 years, 2/3 of whom had associated medical disease. Surgical treatment was conservative in 63 cases: oversewing or ulcer excision, alone (n = 29) or associated with vagotomy (n = 34); and was radical in 15 cases: antrectomy+vagotomy (n = 10) or partial gastric resection (n = 5).

RESULTS

There were 17 (21.8%) postoperative deaths and 19 (24.3%) bleeding recurrences. The causes of death included 9 bleeding recurrences, 7 organ failures and one duodenal leakage. On multivariate analysis, previous medical illness (cirrhosis or cardiac insufficiency (P < 0.001), shock at admission (P < 0.001), prolonged delay until surgery (P < 0.001), and bleeding recurrence (P < 0.001) were independently associated with increased mortality. In contrast, the type of surgical procedure did not influence postoperative mortality, whereas bleeding recurrence was more frequent in case of conservative surgery (P < 0.03) and anticoagulation therapy (P < 0.01).

CONCLUSION

These results suggest that surgical treatment of bleeding peptic ulcer should be proposed early in high-risk patients. A radical procedure should be favoured since it reduces bleeding recurrence rate without increasing operative mortality.

Orthotopic liver transplantation with preservation of the caval and portal flows. Technique and results in 62 cases

Sixty-two OLTs in 61 patients were performed using a technical modification reported recently, including total hepatectomy with preservation of the inferior vena cava, partial clamping of the native vena cava, and side-to-side cavacaval anastomosis. We further modified the technique by adding the early construction of a temporary end-to-side portacaval shunt, and, more recently, by using an end-to-side caval reconstruction. With this technique, the caval and portal flows were maintained throughout the procedure. Hemodynamic parameters were analyzed prospectively during the operative period and remained stable at all stages of the procedure. Venous bypass was avoided in all cases without need for increased fluid infusion. Operative time and transfusion requirements were 6.8 +/- 1.6 hr and 9.8 +/- 4.3 U of packed RBC, respectively. There were no specific complications or deaths due to the technique used and hospital mortality was 10% (6/61). The technique used in this study is a safe adjunct to the technical armamentarium of clinical liver transplantation. Its main advantage seems to be hemodynamic stability throughout the procedure, obviating the need for venous bypass or fluid overload.

Multimodal adjuvant treatment and liver transplantation for advanced hepatocellular carcinoma. A pilot study

BACKGROUND

Orthotopic liver transplantation has been used in a large number of patients with primary liver cancer because it increases the possibilities of resection of large tumors. Despite isolated cases of prolonged survival, however, the results of liver transplantation for advanced tumors have been universally disappointing because of high rates of tumor recurrence. In an attempt to reduce the recurrence rate, a pilot study testing a multimodal adjuvant treatment in patients undergoing liver replacement for hepatocellular carcinoma was undertaken.

METHODS

The treatment consisted of preoperative hepatic arterial chemoembolization (iodized oil, doxorubicin, and gelatin sponge) and radiotherapy (5 Gy in one fraction immediately before surgery), and postoperative systemic chemotherapy with mitoxantrone. Nine patients entered this study. The tumor was solitary in two cases (5 cm and 8 cm) and multifocal in seven cases (2-9 nodules, 3-9 cm). The postoperative TNM stages were II in one case, III in one case, and IVA in seven cases.

RESULTS

Chemoembolization and radiotherapy were performed in seven cases each (five patients had both treatments). All patients underwent liver transplantation with conventional immunosuppression. One patient died of heart failure 4 days after surgery. The remaining eight patients received 4 to 10 courses of chemotherapy (mean 9). The main toxicity of chemotherapy was leucopenia. Two patients died of recurrence: one at 7 months and one at 11 months. Six patients are alive, five of them without evidence of disease, with a mean follow-up of 30 months (range 16-45) after liver transplantation. The 3-year actuarial survival is 64%.

CONCLUSIONS

These results show that an aggressive adjuvant therapy can be used in association with liver transplantation in the treatment of advanced hepatocellular carcinoma without increased mortality and suggest that such a protocol could be effective in preventing tumor recurrence.

The recipient splenic artery for arterialization in orthotopic liver transplantation

Adequate hepatic arterial reconstruction is essential for successful liver transplantation. In the case of insufficient recipient hepatic arterial flow, most surgeons recommend the use of the aorta for arterialization of the graft. We report here on a technique in which the recipient splenic artery is used in such a setting. The splenic artery is dissected from its origin on a 3-to-4 cm segment and divided. The proximal segment is flipped to the right and anastomosed to the graft's celiac axis in an end-to-end fashion. This technique was used in 7 of 79 orthotopic liver transplantations (9%) because the native hepatic artery was deemed to be inadequate for anastomosis. There were no complications related to the use of this technique and no arterial thromboses. Arterialization of hepatic grafts using the recipient proximal splenic artery is a simple, safe, and efficient technique that can be recommended in the presence of an inadequate recipient hepatic arterial flow.

An analysis of the communication of adult residents of a long-term care hospital as perceived by their caregivers

Different groups of caregivers (nurses, orderlies, professionals, student orderlies and volunteers) who were in frequent interaction with residents from a long-term care hospital were interviewed with a nominal group process. They were asked to identify concrete situations of communication in which residents with no trouble communicating, residents with aphasia and residents with dementia need to express and/or comprehend a message. A total of 196 statements were recorded and coded using a qualitative approach into different categories of communication acts specific to daily life situations and several categories of generic communication acts, which are unrelated to the daily routine of care and treatment. The results show that communication in daily life situations varies little in relation to the different residents. However, residents with language disorders are perceived to be less involved in generic communication acts than residents with no communication disorder. They also demonstrate that the perceptions of communication of the different caregivers vary. The results are discussed in relationship to the conception of an evaluation instrument for language-impaired long-term care residents, which will help in determining intervention as well as the objective evaluation of its effects.

Management of breast cancer in the elderly

The management of breast cancer in elderly women was analysed by a retrospective study of 150 women over 70 years old referred to our department between 1984 and 1988. 80 were T1-T2, 33 were T3 and 34 were T4. 107 were N0 and 43 were N1-N2. 16 women (11%) were in poor health, preventing conventional treatment. Treatment choice varied with age: 60% of the women aged 70-79 (group 1) and 23% of the oldest women (group 2) were treated conventionally. The use of surgery decreased with age and surgical procedures were conventional in only 85% of the group 1 women and in 56% of the group 2 women. Definitive radiation therapy was used more frequently in the oldest women, as was primary hormone therapy. Quality of follow-up also varied with age. Five-year survival rates were still high in both groups while relapses were frequent. Breast cancer was consequently a frequent cause of death. The increase in the proportion of elderly people with breast cancers over the next few years will require validated guidelines. Specific protocols and specific rules of management must be drawn up.

Effect of phenytoin on acute lung injuries in unanesthetized sheep

OBJECTIVE

To determine if the intravenous administration of phenytoin attenuates or prevents acute experimental lung injury.

DESIGN

Placebo-controlled, longitudinal animal investigative study.

SETTING

University research laboratory.

SUBJECTS

Sixteen yearling female lambs weighing 30 +/- 3 kg.

INTERVENTION

After administration of anesthesia, the animals were endotracheally intubated and mechanically ventilated. Using sterile techniques, four thoracotomies were performed. Through the left fourth intercostal space, cannulas for pressure measurements were inserted directly into the main pulmonary artery and left atrium. An ultrasound flow cuff for determination of cardiac output was placed around the main pulmonary artery. Through the left tenth intercostal space, the diaphragmatic and mediastinal parietal pleura were widely cauterized. Through the right tenth intercostal space, the caudal mediastinal lymph node was identified and divided at the caudal margin of the right pulmonary ligament, and a 1- to 2-cm portion of the node distal to the ligament was resected. The diaphragmatic and mediastinal parietal pleura were widely cauterized. Through the right sixth intercostal space, the efferent duct (or ducts) was identified, ligated at the site of entry into the thoracic duct, and cannulated. The lymph cannula was brought to the outside of the thorax through a separate stab wound.

MEASUREMENTS AND MAIN RESULTS

Unanesthetized sheep were studied 7 to 10 days after surgery. Hemodynamic, lung fluid balance, and arterial blood variables were measured in uninjured sheep and in sheep injured by intravenous infusions of Escherichia coli endotoxin (1 microgram/kg iv over 30 mins), air bubbles (0.056 to 0.074 mL/kg/min over 4 hrs), or oleic acid (0.06 mL/kg over 1 hr). The sheep were studied when untreated and after pretreatment with phenytoin. We found that the expected increase in protein-rich lung lymph flow with injuries, resulting from increased microvascular permeability in the lungs, was attenuated by phenytoin when the lungs were injured by endotoxin or air bubbles. In contrast, phenytoin had no effect on oleic acid-induced lung injury or on uninjured lungs.

CONCLUSIONS

Phenytoin attenuates acute lung injuries in sheep that are thought to be caused by stimulation of host inflammatory responses (e.g., endotoxin and air bubbles), but has no effect on direct injuries to the lungs (e.g., oleic acid). A plausible mechanism for this finding is phenytoin inhibition of polymorphonuclear leukocyte function.

Differences in the transbilayer and lateral motions of fluorescent analogs of phosphatidylcholine and phosphatidylethanolamine in the apical plasma membrane of bovine aortic endothelial cells

In the plasma membrane of various eucaryotic cell types, in particular blood platelets and erythrocytes, it is known that phospholipids are asymmetrically distributed between the two leaflets of the lipid bilayer and that this transverse asymmetry is controlled by an aminophospholipid translocase activity. In this respect, it was of interest to check whether there are differential transbilayer movements between amino- and neutral phospholipids in the apical plasma membrane of vascular endothelial cells which form the inner nonthrombogenic lining of the large blood vessel. In the first step we compared the transbilayer localization and also the rate of lateral motion of two fluorescent analogs of phosphatidylcholine and phosphatidylethanolamine, namely C6-NBD-PC and C6-NBD-PE, inserted into the apical plasma membrane of bovine aortic endothelial cells, in vitro. By the use of back-exchange experiments we have found that C6-NBD-PC could be removed from the cell membrane toward the culture medium regardless of the incubation conditions used, i.e., just after cell labeling at 0 degrees C or even after further cell incubation for 1 h at 0 or 20 degrees C. In contrast, C6-NBD-PE could be removed only when the cells were maintained at 0 degrees C. After incubation for 1 h at 20 degrees C, 85% of the probe molecules remained nonexchangeable, indicating probe translocation from the outer to the inner leaflet of the lipid bilayer. This "flip" process, which occurred at 20 degrees C, was abolished when the endothelial cells were preincubated with N-ethylmaleimide, diamide, vanadate (VO4(3-)) and vanadyl (VO2+) ions, a set of substances which inhibit aminophospholipid translocase activity in various systems, and with a combination of sodium azide and 2-deoxyglucose which led to nearly complete ATP depletion in the cells. Fluorescence recovery after photobleaching experiments were also carried out to specify more precisely the localization and dynamics of the probes in the two leaflets of the plasma membrane lipid bilayer. They produced lateral diffusion coefficients D of 1.2 +/- 0.05 x 10(-9) cm2/s for C6-NBD-PC and 2.8 +/- 0.3 x 10(-9) cm2/s for C6-NBD-PE, when the two probes were located in the outer leaflet of the plasma membrane, just after cell labeling at 0 degree C.(ABSTRACT TRUNCATED AT 400 WORDS)

Orthotopic liver transplantation in the presence of partial or total portal vein thrombosis: problems in diagnosis and management

From January 1989 to May 1992, 70 orthotopic liver transplantations (OLT) were performed in 69 patients, 53 of whom had cirrhosis (77%). Eleven patients (16%) had preoperative partial or total portal vein thrombosis (PVT). Ten of these patients had cirrhosis of various causes. PVT was total in three cases and partial in eight. Total PVT was detected preoperatively in all three cases. By contrast, partial PVT was diagnosed preoperatively in only three of the eight cases. In the five other cases of partial PVT, the obstruction was discovered intraoperatively during dissection of the portal vein. Surgical management of PVT consisted of phlebothrombectomy in ten cases followed by usual end-to-end portal anastomosis in nine cases and anastomosis of the graft's portal vein to the splenomesenteric confluence in one case. Atypical anastomosis of the graft's portal vein to a dilated choledocal vein was performed in one case of total PVT. There were no deaths or complications related to the presence of preoperative PVT or to its management. One patient died postoperatively of primary graft nonfunction at day 5. One patient had arterial thrombosis 3 months after OLT and was successfully retransplanted. Two patients died of recurrent carcinoma 3 and 7 months after OLT. Eight patients are alive 4 to 39 months after OLT. We conclude from this series that (1) the prevalence of preoperative PVT among patients transplanted for advanced cirrhosis may be high (19% of the cirrhotics in this series); (2) PVT is often partial and so difficult to diagnose preoperatively; (3) PVT, even when total, can be managed successfully during surgery and does not seem to affect survival.

Comparison of intramuscular and intravenous quinine for the treatment of severe and complicated malaria in children

To compare the efficacy and side effects of intramuscular (i.m.) and intravenous (i.v.) quinine, children in Mozambique with severe and complicated malaria between 6 months and 7 years were randomized to treatment with i.m. or i.v. quinine, both in a dosage of quinine dihydrochloride 20 mg/kg followed by 10 mg/kg every 8 h. Of 57 children treated with i.m. quinine, 4 died, 3 had neurological sequelae and 2 had sterile intramuscular abscesses. Of 47 children treated with i.v. quinine, 6 died and 1 had neurological sequelae. The mean parasite clearance time was 58.6 h in the i.m. group and 59.3 h in the i.v. group. Mean temperature clearance times were 56.1 and 51.8 h, and mean coma clearance times 40.4 and 38.7 h, respectively. None of these differences was statistically significant. Mean trough and peak concentrations of quinine were almost identical in the 2 groups, ranging from 10.5 to 12.6 mg/L, which is in the therapeutic non-toxic range. It is concluded that i.m. quinine is as effective as quinine by i.v. infusion in children with severe and complicated malaria; that minor local side effects can probably be avoided by using diluted quinine for i.m. injection; and that the optimal dose regimen for children with severe and complicated malaria in Africa at present is probably quinine salt 20 mg/kg followed by 10 mg/kg every 12 h.

[Liver transplantation associated with combined adjuvant treatment in hepatocellular carcinoma. Feasibility and preliminary results]

Combined adjuvant therapy was prospectively assessed in 7 patients receiving orthotopic liver transplantation for hepatocellular carcinoma complicating cirrhosis. The protocol included hepatic arterial chemotherapy while waiting for transplant, immediate preoperative liver irradiation, and early postoperative chemotherapy. There were no postoperative deaths, and morbidity included mainly hematologic toxicity of chemotherapy. Two patients died of tumor recurrence 6 and 14 months after transplant. The remaining 5 patients are alive and free of disease with a follow-up of 7 to 26 months. These results show the feasibility of aggressive adjuvant therapy in patients transplanted for hepatocellular carcinoma and suggest a possible effect of such a protocol on the prevention of tumor recurrence.

Polyadenylic-polyuridylic acid as an adjuvant in resectable colorectal carcinoma: a 6 1/2 year follow-up analysis of a multicentric double blind randomized trial

In a double blind study, patients with operable carcinoma of the colon and the upper rectum, who have undergone a macroscopically complete resection of their tumor, were randomized to receive either (i) polyadenylic-polyuridylic acid (AU), one i.v. injection of 60 mg (in 50 ml of solution) once a week for 6 weeks, or (ii) a placebo (P) one i.v. injection of 50 ml of a saline solution with the same schedule. From January 1983 to December 1986, 288 patients were enrolled: 145 in AU group and 143 in P group. The main clinical and pathological characteristics were equally distributed throughout the two groups. There was a significant difference (P < 0.02) in the overall survival (OS) between the two groups, in favor of the P group. The 5-year OS rate was 68% (SD = 4%) in the AU group versus 81% (SD = 3%) in the P group. Thus, AU as a single adjuvant, appears to be ineffective and therefore has no indication in the treatment of colorectal carcinoma.

Effect of Feeding Lactic Acid Bacteria and Fermented Milk on Specific and Nonspecific Immune Reponses of Mice Infected With Klebsiella pneumoniae AD-1

The diets of six groups of weaned mice were supplemented with ultra high temperature (UHT) milk containing a washed suspension of lactic acid bacteria (mixture of 8 strains) or with UHT milk fermented by the same strains and heat-treated or not. Control groups received physiological saline or UHT milk only. The mice were infected intranasally by Klebsiella pneumoniae AD-1 on the 13th d of feeding. The effect on the immune system (specific and nonspecific) before and after infection was evaluated by measuring the phagocytosis of alveolar macrophages (using zymosan particles) and by measuring of total immunoglobulin G and A levels in serum and in pulmonary fluid (using the enzyme-linked immunosorbent assay method). Postinfection survival was 0.7 d longer for mice receiving fermented milk than for the saline control group. The percent phagocytosis did not vary significantly, while serum immunoglobulin G levels differed between mice fed fermented milk and those fed bacterial suspensions in unfermented milk. Fermentation appears to be essential for the beneficial effects on the immune system and survival time; this effect no longer occurs after pasteurization of fermented milk.

Hepatic arterial infusion of floxuridine in patients with liver metastases from colorectal carcinoma: long-term results of a prospective randomized trial

PURPOSE

A multicentric randomized study that compared patients who received intrahepatic arterial infusion (HAI) to a group of patients who did not receive HAI (control group) was performed for unresectable hepatic metastases from primary colorectal carcinoma.

PATIENTS AND METHODS

One hundred sixty-six patients were assigned randomly to HAI of floxuridine (5 fluoro-2'deoxyuridine [FUDR]) 0.3 mg/kg/d for 14 days every 4 weeks or to the control group; this latter group, depending on the investigator's choice, was either under observation or received systemic fluorouracil (5-FU). The same regimen of systemic 5-FU also was administered to the HAI group in the event of extrahepatic progression. No crossover from the control group to the HAI group was permitted. The mean duration of follow-up was 54 months (range, 31 to 72), and 163 patients were analyzed.

RESULTS

A significant improvement was observed in the survival rate for the 81 patients assigned to HAI group (P less than .02) with a 1-year survival rate of 64% versus 44% in the control group (82 patients). The 2-year survival rate was 23% versus 13%. The median survival was 15 months versus 11 months for the HAI group and the control group, respectively. Survival was better for patients with a less than 30% liver involvement, and for those treated in more specialized centers. The hepatotoxic effects of HAI were observed in 47 patients (chemical hepatitis [n = 28], and biliary sclerosis [n = 19]). The 1-year rate of sclerosing cholangitis was equal to 25%. Gastrointestinal toxicity was infrequent and consisted of gastritis or diarrhea.

CONCLUSIONS

Therapy with HAI of FUDR improves the survival of patients with liver metastases over colorectal carcinoma. However, the methods that are used to diminish the toxicity of HAI and efficient systemic chemotherapy, such as a combination of 5-FU and leucovorin, are required to prevent extrahepatic metastases.

Expression of intermediate filament proteins in TPA-induced MPC-11 and HL-60 cells

Under normal culture conditions, the tumor cell lines MPC-11 and HL-60 exhibit high rates of proliferation and show a peculiar expression of intermediate filament proteins as they appear to synthesize only lamin B. A 48-h exposure of murine plasmacytomas MPC-11 to the phorbol ester TPA reduces their growth and induces vimentin synthesis without affecting the composition of their nuclear lamina. When applied to human leukemic promyelocytes HL-60, such treatment promotes their maturation into macrophage-like cells: their proliferative ability is suppressed, a differentiated phenotype is developed, and their content in intermediate filament proteins now includes vimentin and a full complement of lamins A, B, and C. In the present study, a kinetic analysis of vimentin and lamin A/C expression in relation to proliferation and differentiation has been performed in these two cellular systems. Proliferation rates of MPC-11 and HL-60 populations were evaluated by monitoring cell growth and measuring thymidine incorporation. Maturation of HL-60 cells was assessed by Giemsa staining and percentage of adherent cells. Expression of vimentin and lamins A/C was analyzed using immunofluorescence and immunoblotting techniques. Our data show that there is a relationship between the level of vimentin expression and the extent of growth inhibition in both systems. They also suggest that the expression of lamins A/C during the TPA-induced maturation of HL-60 promyelocytes might be part of the processes which lock these cells into the macrophage pathway.

Cellular reaction to the Vascugraft polyesterurethane vascular prosthesis: in vivo studies in rats

The biocompatibility of Vascugraft, a polyesterurethane vascular prosthesis manufactured by Braun-Melsungen AG, was assessed by immunofluorescence and histological studies. Discs, 1 cm2, of Vascugraft prosthesis were implanted into the peritoneal cavity of rats. Results were compared with Impra, GORE-TEX and Mitrathane prostheses and a control group. Animals were killed at 1, 2, 6, 9 and 12 wk. Total T cells, T helper cells, T suppressor cells and activated T lymphocytes expressing Interleukin-2 receptors were quantified by a cytofluorometric technique in the peripheral blood of rats. For each period of implantation, all vascular prostheses showed no significant change in the percentage of total T cells, T subsets and T cells expressing Interleukin-2 receptors when compared to the control group. Histological examination of the tissue reaction surrounding the Vascugraft revealed a mild inflammatory reaction, similar to the one observed with both polytetrafluoroethylene grafts. However, the rate and the degree of encapsulation were different between grafts. The Vascugraft prosthesis was well encapsulated 2 wk after implantation, whereas inhibition of fibroblastic proliferation into the graft wall and surrounding both polytetrafluoroethylene grafts was observed for each period of implantation. The Mitrathane prosthesis exhibited a moderate inflammatory response, characterized by a high level of activation on fibroblasts compared to other grafts.

External irradiation prior to conservative surgery for breast cancer treatment

From 1981 to 1987, 138 patients with breast cancer unsuitable for primary tumorectomy received initial external radiotherapy (45 Gy/25f/35d) in order to reduce the tumor volume so that secondary limited surgery could be performed. There were 81 T2 and 57 T3. Fifty-seven percent of the patients had a tumor larger than 4.5 cm. After completion of the radiotherapy, 22 patients (16%) showed no more evidence of a tumor either clinically or radiologically and received a boost of 25 Gy. In 52 cases (38%) the tumor regression allowed for secondary tumorectomy followed by a boost of 20 Gy. Sixty-four patients (46%) showed either little or no tumor regression: radical surgery was performed in 14 cases (10%) and high dose boost curietherapy (37 Gy) in the 50 (36%) remaining patients who refused mastectomy. Breast conservation in good condition was thus obtained in 74 patients (54%). Sufficient tumor regression to allow secondary tumorectomy was more often observed in T2 than in T3, in poorly differentiated tumors or mucinous type, and in tumor with well defined mammographic aspects. Actuarial 5-year local control and disease-free survival rates after limited surgery were, respectively, 90% and 73%. No particular complications were observed after secondary tumorectomy. This therapeutic approach is encouraging in patients with large T2 and T3 breast tumors, but a longer follow-up is required to assess definitive conclusions.

Conservative treatment for breast cancer: long-term results (15 years)

From 1961 to 1974, 245 patients with unilateral "operable" breast cancer (25% T1, 56% T2, 19% T3) were treated with breast conservation and irradiation at the Gustave Roussy Institute (1961-1969) or at the Henri Mondor Hospital (1970-1974). The minimum follow-up is 15 years. Most patients with T greater than 3 cm underwent radiation therapy with the tumor in place, while the greater part of patients with T less than 3 cm received radiation therapy after tumorectomy. The breast and draining lymph node areas received widefield telecobalt irradiation to 45 Gy. The dose to the tumor site was boosted using iridium-192 implantation. Additional irradiation was given to the internal mammary and lower axillary nodes using an electron beam. The 15 years NED survival rate was 63%, 51% and 26% for T1, T2 and T3 tumors, respectively. The NED survival for T less than or equal to 1 cm was 86%. The local recurrence rate was 8, 12 and 19% for T1, T2 and T3 tumors, respectively. Of the patients with local recurrence, 85% underwent surgical salvage. Complications were rare. Cosmetic results were satisfactory in most patients including the T3 group. The proportion of breasts conserved among patients living NED at 15 years, was 97, 88 and 93% for T1, T2 and T3 tumors, respectively. In 1980, after almost 20 years experience using breast conserving techniques, we modified our treatment policies in close collaboration with our surgical team, hel cbye extending the indications for tumorectomy and associating routine surgical exploration of the lower axilla.