ABSTRACT
INTRODUCTION: Duodenal neuroendocrine tumours (D-NETs) have a low incidence; however, their diagnosis has been increasing. Features such as tumour location, size, type, histological grade, and stage were used to adapt the treatment to either endoscopic (ER) or surgical (SR) resections. There is no consensus regarding the definitive treatment. The authors' study aimed to describe the management of non-metastatic, well-differentiated D-NETs in France and its impact on patient survival. METHODS: A registry-based multicenter study using prospectively collected data between 2000 and 2019, including all patients managed for non-metastatic G1 and G2 D-NETs, was conducted in the GTE group. RESULTS: A total of 153 patients were included. Fifty-eight benefited from an ER, and 95 had an SR. No difference in recurrence-free survival (RFS) was observed regardless of treatment type. There was no significant difference between the two groups (ER vs. SR) in terms of location, size, grade, or lymphadenopathy, regardless of the type of incomplete resection performed or regarding the pre-therapeutic assessment of lymph node invasion in imaging. The surgery allowed for significantly more complete resection (patients with R1 resection in the SR group: 9 vs. 14 in the ER group, P <0.001). Among the 51 patients with positive lymph node dissection after SR, tumour size was less than or equal to 1 cm in 25 cases. Surgical complications were more numerous ( P =0.001). In the sub-group analysis of G1-G2 D-NETs between 11 and 19 mm, there was no significant difference in grade ( P =0.977) and location ( P =0.617) between the two groups (ER vs. SR). No significant difference was found in both morphological and functional imaging, focusing on the pre-therapeutic assessment of lymph node invasion ( P =0.387). CONCLUSION: Regardless of the resection type (ER or SR) of G1-G2 non-metastatic D-NETs, as well as the type of management of incomplete resection, which was greater in the ER group, long-term survival results were similar between ER and SR. Organ preservation seems to be the best choice owing to the slow evolution of these tumours.
Subject(s)
Duodenal Neoplasms , Neuroendocrine Tumors , Humans , Female , Male , France , Neuroendocrine Tumors/mortality , Neuroendocrine Tumors/pathology , Neuroendocrine Tumors/surgery , Neuroendocrine Tumors/therapy , Middle Aged , Duodenal Neoplasms/surgery , Duodenal Neoplasms/pathology , Duodenal Neoplasms/mortality , Aged , Adult , Cohort Studies , RegistriesABSTRACT
The sulcus of the caudate process is a horizontal groove on the inferior face of the liver. Its prevalence has not previously been determined. Because of its location, it represents a helpful extra-biliary landmark that could be used in biliary surgery to decrease bile duct injury. The goal of this study is to determine the prevalence of Rouviere's sulcus and describe its anatomy and relevant surgical applications. We conducted a literature review on the various characteristics of the sulcus, selecting anatomical clinical studies and dissections. We performed 10 cadaveric dissections in the Laboratory of Anatomy at Purpan University to determine the contents. We selected 12 anatomical studies, conducted between 1924 and January 1st, 2020, which included 2394 patients. The prevalence of the sulcus is 78.24% ± 9.1. Classification of Singh was used to describe anatomical characteristics. Type I ("deep sulcus") was identified in 50.4% ± 9.8 of cases, mostly consisting of Type Ia (open). Type II ("slit-like") was estimated to account for 13.3% ± 13.2, whereas Type III ("scar") described 12.3% ± 8.0. Average dimensions were estimated for length (26 mm ± 5.7), width (6.5 mm ± 1.5), and depth (7.9 mm ± 1.75). The content of the sulcus consists of the right portal vein and its division, the right hepatic artery, along with the right hepatic bile duct. The sulcus determines the orientation of the common bile duct. The sulcus of the caudate process is a reliable extra-biliary landmark, which presents a useful tool for reducing bile duct injuries during hepatobiliary surgery.
Subject(s)
Anatomic Variation , Liver/anatomy & histology , HumansABSTRACT
PURPOSE: The optimal dose in esophageal cancer patients treated with definitive chemoradiation (CRT) remains debated. We herein report on the dosimetric results, treatment-related toxicities and long-term outcomes of escalated dose up to 60Gy delivered with intensity-modulated radiotherapy (IMRT). MATERIALS AND METHODS: All consecutive patients that received a definitive CRT>50Gy for an unresectable esophageal carcinoma between 2010 and 2015 were retrospectively evaluated for this study. Methodology included data base search, delayed toxicity grading, statistical testing including frequency analysis and survival analysis. RESULTS: A total of 51 patients were irradiated for a squamous cell carcinoma (86.3%) or an adenocarcinoma (13.7%). The median age at diagnosis was 62 years. Seven patients were simultaneously irradiated for another synchronous primary tumor. Forty-six patients (90.2%) received concurrent platin-based chemotherapy. The median prescribed doses were 60Gy (54-66) and 48Gy (44.8-56) delivered in 30 (27-35) fractions to the high and the low risks PTV respectively. The mean dose delivered to the lungs was 11.4Gy (IC 95%: 4.8-19.8), the median volumes receiving up to 20Gy (V20) and 30Gy (V30) were 13.5% (3.0-46.0) and 4.6% (0.7-19.8) respectively. The mean dose delivered to the heart was 13.9Gy (IC 95%:0.3-31.3) with a median V40 of 3.3% (0.0-25.0). One treatment-related death occurred within days after RT completion (neutropenic aplasia). After a median follow-up of 2.7 years (95% CI: 1.9-4.3), the 2-year overall survival, disease free survival and loco-regional control rates were 53.6%, 42.0% and 72.8% respectively. Delayed treatment related-toxicities ≤grade 3 occurred among 25 patients (62.5%) mostly esophageal stricture (79.2%). CONCLUSION: We demonstrated in this study that dose escalation using IMRT in combination with platin-based chemotherapy as a definitive treatment for esophageal carcinoma is safe and results in higher loco-regional and control survival when compared to previously reported data.
Subject(s)
Adenocarcinoma/therapy , Carcinoma, Squamous Cell/therapy , Chemoradiotherapy/methods , Esophageal Neoplasms/therapy , Radiation Tolerance , Radiotherapy, Intensity-Modulated/methods , Adenocarcinoma/mortality , Adenocarcinoma/pathology , Adult , Aged , Aged, 80 and over , Antineoplastic Combined Chemotherapy Protocols/administration & dosage , Antineoplastic Combined Chemotherapy Protocols/adverse effects , Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Carcinoma, Squamous Cell/mortality , Carcinoma, Squamous Cell/pathology , Chemoradiotherapy/adverse effects , Disease-Free Survival , Dose Fractionation, Radiation , Esophageal Neoplasms/mortality , Esophageal Neoplasms/pathology , Esophageal Stenosis/etiology , Female , Fluorouracil/administration & dosage , Heart/radiation effects , Humans , Leucovorin/administration & dosage , Lung/radiation effects , Male , Middle Aged , Organoplatinum Compounds/administration & dosage , Organs at Risk/radiation effects , Radiotherapy, Intensity-Modulated/adverse effects , Retrospective Studies , Time Factors , Treatment OutcomeABSTRACT
Management of resectable esophageal carcinoma is based on a multimodal treatment associating neo-adjuvant chemoradiation before surgery. This therapeutic sequence allows a disease-free survival rate at 2 years around 45% but remains associated with a high post-operative morbidity. In case of definitive chemoradiotherapy, the dose delivered to the macroscopic disease is a controversial topic since decades and the prognosis of patients treated in this setting at the dose of 50Gy remains poor. This article proposes a review of the main published data and the ongoing studies related to the management of these patients.
Subject(s)
Carcinoma/therapy , Chemoradiotherapy, Adjuvant/methods , Esophageal Neoplasms/therapy , Neoadjuvant Therapy , Humans , Preoperative Care/methods , Radiotherapy Dosage , Radiotherapy, Intensity-Modulated/methodsABSTRACT
The restoration of CD4+ T cells, especially T-helper type 17 (Th17) cells, remains incomplete in the gut mucosa of most human immunodeficiency virus type 1 (HIV-1)-infected individuals despite sustained antiretroviral therapy (ART). Herein, we report an increase in the absolute number of CXCR3+ T cells in the duodenal mucosa during ART. The frequencies of Th1 and CXCR3+ CD8+ T cells were increased and negatively correlated with CCL20 and CCL25 expression in the mucosa. In ex vivo analyses, we showed that interferon γ, the main cytokine produced by Th1 and effector CD8+ T cells, downregulates the expression of CCL20 and CCL25 by small intestine enterocytes, while it increases the expression of CXCL9/10/11, the ligands of CXCR3. Interleukin 18, a pro-Th1 cytokine produced by enterocytes, also contributes to the downregulation of CCL20 expression and increases interferon γ production by Th1 cells. This could perpetuate an amplification loop for CXCR3-driven Th1 and effector CD8+ T cells recruitment to the gut, while impairing Th17 cells homing through the CCR6-CCL20 axis in treated HIV-1-infected individuals.
Subject(s)
HIV Infections/metabolism , Interferon-gamma/metabolism , Interleukin-18/metabolism , Intestinal Mucosa/metabolism , Intestine, Small/metabolism , Receptors, CXCR3/metabolism , Th17 Cells/metabolism , Anti-Retroviral Agents/therapeutic use , CD4-Positive T-Lymphocytes/metabolism , CD8-Positive T-Lymphocytes/metabolism , Cell Movement , Chemokine CCL20/metabolism , Chemokine CXCL10/metabolism , Chemokine CXCL11/metabolism , Chemokine CXCL9 , Chemokines, CC/metabolism , Cytokines/metabolism , HIV Infections/therapy , Humans , Th1 Cells/metabolismABSTRACT
Alginate and chitosan are polysaccharides that are widely used in the biomedical field, especially as wound dressings. Controlled bioadhesion is an advanced functionality that offers the potential to reduce injuries due to the stripping-off of the biomaterial. Herein, we report the efficient grafting of poly-N(isopropylacryamide) (PNIPAM), a thermosensitive polymer that exhibits a lower critical solution temperature (LCST) at 32 °C on the alginate/chitosan polyelectrolyte complex (PEC) surface. In vitro studies did not exhibit a cytotoxic effect, and cells adhered preferentially on the LCST on PNIPAM grafted surfaces, as reported in the literature. Ex vivo investigations revealed that the adhesive behavior of the biomaterials was not the same on the liver and pancreas. The effect of the temperature on the bioadhesion to organs was unexpected, as PNIPAM surfaces exhibited higher adhesion at low temperature. The PNIPAM was therefore able to confer PEC matrix thermosensitivity, but due to the application force, interactions between PNIPAM chains and their substrate could influence bioadhesion on tissues.
Subject(s)
Acrylic Resins/chemistry , Biocompatible Materials/chemistry , Temperature , Acrylic Resins/chemical synthesis , Acrylic Resins/metabolism , Alginates/chemistry , Alginates/metabolism , Animals , Biocompatible Materials/chemical synthesis , Biocompatible Materials/metabolism , Cell Adhesion , Cells, Cultured , Chitosan/chemistry , Chitosan/metabolism , Humans , Liver/metabolism , Pancreas/metabolism , Polymers/chemistry , Polymers/metabolism , Surface Properties , Swine , Tissue Adhesives/chemistry , Tissue Adhesives/metabolismABSTRACT
INTRODUCTION: The indications for use of biological mesh prostheses are very limited because of their high cost, but include parietal repair in a contaminated setting. Their efficacy has been questioned by several recent studies. We therefore studied the results of all of our patients who received a biological prosthesis, including hernia recurrence and infectious complications. PATIENTS AND METHODS: We retrospectively reviewed the outcomes of 68 patients who underwent biological prosthesis placement from 2009 to 2015 in a single center. RESULTS: The site of implantation was on the anterior abdominal wall in 49 (72%) of cases, in the pelvis in 19 (28%). The median follow-up was 19 months. In the early post-operative period, 22 (32.3%) of patients presented with wall abscess; eight (11.7%) underwent surgical revision and seven (10.2%) underwent interventional radiological drainage. In the medium term, 41/56 (73%) had a late complication; 32 (57%) of the patients developed recurrent herniation and 15 (26.7%) of them were re-operated. In addition, nine (16%) of patients developed a late surgical site infection and eight (14.2%) a chronic residual infection. In multivariate analysis, the risk factors for recurrence were parastomal hernia (P=0.007) and a history of recurrent hernia (P=0.002). CONCLUSION: A majority of patients developed recurrent incisional herniation in the medium term. This puts the use of biological prostheses into question. These results need to be compared to those of semi-absorbable prostheses.
Subject(s)
Abdominal Wall/surgery , Bioprosthesis/adverse effects , Hernia, Ventral/surgery , Postoperative Complications/epidemiology , Surgical Mesh/adverse effects , Abscess/epidemiology , Aged , Drainage/methods , Female , Follow-Up Studies , Herniorrhaphy/adverse effects , Herniorrhaphy/statistics & numerical data , Humans , Incisional Hernia/epidemiology , Incisional Hernia/etiology , Male , Middle Aged , Postoperative Complications/etiology , Recurrence , Regression Analysis , Reoperation/statistics & numerical data , Retrospective Studies , Surgical Stomas/adverse effects , Surgical Wound Infection/epidemiology , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: Spleen-preserving distal pancreatectomy with resection of the splenic vessels (VR-SPDP) is an effective procedure. However, hemodynamic changes in splenogastric circulation may lead to the development of gastric varices (GV) with a risk of gastrointestinal (GI) bleeding. This retrospective study aimed to assess the long-term postoperative clinical follow-up of patients and review the late postoperative abdominal computed tomography (CT) or endoscopic examination. METHODS: From 1988 to 2015, 48 consecutive VR-SPDP for benign or low-grade malignant disease were included. Late postoperative follow-up was undertaken with the use of a prospective database and assessment undertaken by CT and/or endoscopy. RESULTS: The median follow-up was 76 months (range: 12-334 months). Two patients were lost to follow-up. Gastrointestinal hemorrhage occurred in one patient. Endoscopy and abdominal CT showed submucosal GV in five patients. Ten patients had perigastric varices (27%), but none developed clinical complications from their varices. All varices occurred within one year after distal pancreatectomy and remained stable during follow-up. DISCUSSION: Asymptomatic varices frequently occurred in patients who underwent VR-SPDP, but bleeding risk seemed low. Abdominal CT could identify GV and distinguish submucosal varices with a higher risk of gastric bleeding.
Subject(s)
Esophageal and Gastric Varices/etiology , Gastrointestinal Hemorrhage/etiology , Organ Sparing Treatments/adverse effects , Pancreatectomy/adverse effects , Splenic Artery/surgery , Splenic Vein/surgery , Stomach Diseases/etiology , Adult , Aged , Databases, Factual , Esophageal and Gastric Varices/diagnosis , Female , Follow-Up Studies , Gastrointestinal Hemorrhage/diagnosis , Gastroscopy , Humans , Male , Middle Aged , Pancreatectomy/methods , Retrospective Studies , Risk Assessment , Risk Factors , Stomach Diseases/diagnosis , Time Factors , Tomography, X-Ray Computed , Treatment Outcome , Young AdultABSTRACT
Biomaterials surface design is critical for the control of materials and biological system interactions. Being regulated by a layer of molecular dimensions, bioadhesion could be effectively tailored by polymer surface grafting. Basically, this surface modification can be controlled by radical polymerization, which is a useful tool for this purpose. The aim of this review is to provide a comprehensive overview of the role of surface characteristics on bioadhesion properties. We place a particular focus on biomaterials functionalized with a brush surface, on presentation of grafting techniques for "grafting to" and "grafting from" strategies and on brush characterization methods. Since atom transfer radical polymerization (ATRP) and reversible addition-fragmentation chain transfer (RAFT) polymerization are the most frequently used grafting techniques, their main characteristics will be explained. Through the example of poly(N-isopropylacrylamide) (PNIPAM) which is a widely used polymer allowing tuneable cell adhesion, smart surfaces involving PNIPAM will be presented with their main modern applications.
Subject(s)
Acrylic Resins/chemistry , Biocompatible Materials/chemistry , Adsorption , Cell Adhesion , Humans , Kinetics , Microscopy, Electron, Scanning , Polymerization , Polymers/chemistry , Surface Properties , Temperature , Tissue Engineering/methodsABSTRACT
The gut CD4(+) T cells, particularly the T helper type 17 (Th17) subset, are not completely restored in most HIV-1-infected individuals despite combined antiretroviral therapy, when initiated at the chronic phase of infection. We show here that the CCR6-CCL20 chemotactic axis is altered, with reduced CCL20 production by small intestine epithelial cells in treated HIV-1-infected individuals. This leads to impaired CCR6(+)CD4(+) T-cell homing, particularly Th17 cells, to the small intestine mucosa. In contrast, the frequency of gut FoxP3(+) T regulatory (Treg) cells, specifically the CCR6(-) subset, was increased. The resulting imbalance in the Th17/CCR6(-) Treg ratio and the associated shift from interleukin (IL)-17 to IL-10 and transforming growth factor-ß (TGF-ß) blunts CCL20 production by enterocytes, perpetuating a negative feedback for the recruitment of CCR6(+)CD4(+) T cells to the small intestine in treated HIV-1-infected individuals.
Subject(s)
Anti-HIV Agents/therapeutic use , Chemokine CCL20/immunology , HIV Infections/immunology , Receptors, CCR6/immunology , T-Lymphocytes, Regulatory/immunology , Th17 Cells/immunology , Adult , Antiretroviral Therapy, Highly Active , CD4 Antigens/genetics , CD4 Antigens/immunology , Case-Control Studies , Chemokine CCL20/genetics , Chemotaxis/drug effects , Chemotaxis/immunology , Enterocytes/drug effects , Enterocytes/immunology , Enterocytes/virology , Feedback, Physiological , Female , Forkhead Transcription Factors/genetics , Forkhead Transcription Factors/immunology , Gene Expression Regulation , HIV Infections/drug therapy , HIV Infections/pathology , HIV Infections/virology , HIV-1/drug effects , HIV-1/growth & development , Humans , Interleukin-10/genetics , Interleukin-10/immunology , Interleukin-17/genetics , Interleukin-17/immunology , Intestinal Mucosa/drug effects , Intestinal Mucosa/immunology , Intestinal Mucosa/virology , Intestine, Small/drug effects , Intestine, Small/immunology , Intestine, Small/virology , Lymphocyte Count , Male , Middle Aged , Receptors, CCR6/deficiency , Receptors, CCR6/genetics , Signal Transduction , T-Lymphocytes, Regulatory/drug effects , T-Lymphocytes, Regulatory/virology , Th17 Cells/drug effects , Th17 Cells/virology , Transforming Growth Factor beta/genetics , Transforming Growth Factor beta/immunologyABSTRACT
BACKGROUND: Despite the prevalence of complex ventral hernias, there is little agreement on the most appropriate technique or prosthetic to repair these defects, especially in contaminated fields. Our objective was to determine French surgical practice patterns among academic surgeons in complex ventral hernia repair (CVHR) with regard to indications, most appropriate techniques, choice of prosthesis, and experience with complications. METHODS: A survey consisting of 21 questions and 6 case-scenarios was e-mailed to French practicing academic surgeons performing CVHR, representing all French University Hospitals. RESULTS: Forty over 54 surgeons (74%) responded to the survey, representing 29 French University Hospitals. Regarding the techniques used for CVHR, primary closure without reinforcement was provided in 31.6% of cases, primary closure using the component separation technique without mesh use in 43.7% of cases, mesh positioned as a bridge in 16.5% of cases, size reduction of the defect by using aponeurotomy incisions without mesh use in 8.2% of cases. Among the 40 respondents, 36 had experience with biologic mesh. There was a strong consensus among surveyed surgeons for not using synthetic mesh in contaminated or dirty fields (100%), but for using it in clean settings (100%). There was also a strong consensus between respondents for using biologic mesh in contaminated (82.5%) or infected (77.5%) fields and for not using it in clean setting (95%). In clean-contaminated surgery, there was no consensus for defining the optimal therapeutic strategy in CVHR. Infection was the most common complication reported after biologic mesh used (58%). The most commonly reported influences for the use of biologic grafts included literature, conferences and discussion with colleagues (85.0%), personal experience (45.0%) and cost (40.0%). CONCLUSIONS: Despite a lack of level I evidence, biologic meshes are being used by 90% of surveyed surgeons for CVHR. Importantly, there was a strong consensus for using them in contaminated or infected fields and for not using them in clean setting. To better guide surgeons, prospective, randomized trials should be undertaken to evaluate the short- and long-term outcomes associated with these materials in various surgical wound classifications.
Subject(s)
Attitude of Health Personnel , Hernia, Ventral/surgery , Herniorrhaphy/methods , Practice Patterns, Physicians'/statistics & numerical data , Surgical Mesh , Consensus , Female , France , Health Care Surveys , Herniorrhaphy/instrumentation , Humans , MaleABSTRACT
Gallbladder volvulus is a rare condition caused by torsion of the cholecystic pedicle and is favored by a long or nonexistent cholecystic mesentery. Gallbladder torsion presents clinically as gangrenous cholecystitis. Emergency cholecystectomy is the standard treatment. Lack of awareness of this condition can result in delayed diagnosis and worsen the prognosis of elderly patients.
Subject(s)
Gallbladder Diseases/diagnostic imaging , Torsion Abnormality/diagnostic imaging , Aged, 80 and over , Cholecystectomy , Female , Gallbladder Diseases/surgery , Humans , Radiography , Torsion Abnormality/surgeryABSTRACT
Small bowel adenocarcinoma is a rare tumor. These tumors are more often sporadic but there is some predisposing disease (Crohn disease, genetic syndrome and rarely celiac disease). Diagnosis is usually performed at an advanced stage because of non-specific nature of clinical manifestations. New methods of radiological and endoscopic exploration of small intestine should allow earlier diagnosis. Surgical resection remains the only potentially curative treatment for non-metastasic tumors. The main prognosis factor is lymph nodes involvement. The role of adjuvant chemotherapy is unclear. For metastatic tumors, 5-fluorouracil and platinum salt combination appears to be the most effective chemotherapy despite of the absence of randomized studies. A national prospective cohort study is currently evaluating the results of chemotherapy (recommended protocol: FOLFOX) as adjuvant and palliative treatment of small bowel adenocarcinoma.
Subject(s)
Adenocarcinoma/etiology , Adenocarcinoma/therapy , Intestinal Neoplasms/etiology , Intestinal Neoplasms/therapy , Adenocarcinoma/diagnosis , Adenocarcinoma/epidemiology , Chemotherapy, Adjuvant , Genetic Predisposition to Disease , Humans , Intestinal Neoplasms/diagnosis , Intestinal Neoplasms/epidemiology , Intestine, Small/pathology , Intestine, Small/surgery , Lymphatic Metastasis , Neoplasm Metastasis , Prognosis , Risk FactorsABSTRACT
Major abdominal surgery may be contraindicated in patients with cirrhosis because of the high risk of intraoperative bleeding and postoperative decompensation. Careful preparation of these patients is essential, aimed especially at reducing portal hypertension. We report the case of a patient with cirrhosis complicated by hepatocellular carcinoma, whose portal hypertension manifested almost exclusively by reanastomosis from the umbilical vein. A transjugular intrahepatic portosystemic shunt (TIPS) was placed before surgery to prepare the patient for hepatic resection. In addition to the singularity of the presentation of portal hypertension, this case prompts us to consider neoadjuvant TIPS as a means of preparing these at-risk patients for major abdominal surgery.
Subject(s)
Carcinoma, Hepatocellular/surgery , Hypertension, Portal/complications , Liver Cirrhosis, Alcoholic/complications , Liver Neoplasms/surgery , Portasystemic Shunt, Surgical , Preoperative Care , Carcinoma, Hepatocellular/complications , Female , Humans , Liver Neoplasms/complications , Middle AgedABSTRACT
Clonality analysis of the immunoglobulin heavy chain (IgH) gene is helpful in identifying malignant B cell infiltrates in the bone marrow and is usually carried out on separate aspirates or on the same formalin-fixed decalcified bone marrow specimen. To determine whether the removal of the decalcification step would improve the molecular analysis, we first studied 12 bone marrow specimens with lymphoma infiltration split into a fixed and a small frozen fragment. Both the detection rate of IgH gene monoclonality and DNA quality were found to be superior in the frozen part than in the fixed part. Conversely, to evaluate whether the split would compromise histological analysis, we selected a series of 134 bone marrow specimens obtained from patients with small B cell lymphoma and showing IgH monoclonality on the frozen part. The histological detection rate of infiltrated or suspicious infiltrates (95%) on the fixed part was not altered by saving a frozen part.
Subject(s)
Bone Marrow/pathology , Lymphoma, B-Cell/pathology , Biopsy , Bone Marrow Examination/methods , Cryopreservation , DNA, Neoplasm/analysis , Humans , Immunoglobulin Heavy Chains/genetics , Lymphoma, Follicular/pathology , Neoplasm Invasiveness , Neoplasm Staging/methods , Tissue Fixation/methodsABSTRACT
BACKGROUND: The aim of this study was to evaluate the utility of staging laparoscopy in patients with biliary cancers in the era of modern diagnostic imaging. METHODS: From September 2002 through August 2004, 39 consecutive patients with potentially resectable cholangiocarcinoma underwent preoperative staging laparoscopy before laparotomy. Preoperative imaging included ultrasonography and triphasic computed tomography for all patients and magnetic resonance cholangiography in 35 patients (90%). Final pathological diagnosis included 20 hilar cholangiocarcinomas (HC), 11 intrahepatic cholangiocarcinomas (IHC), and eight gallbladder carcinomas (GBC). RESULTS: During laparoscopy, unresectable disease was found in 14/39 patients (36%). The main causes of unresectability were peritoneal carcinomatosis (11/14) and liver metastases (5/14). At laparotomy, nine patients (37%) were found to have advanced disease precluding resection. Vascular invasion and nodal metastases were the main causes of unresectability during laparotomy (eight out of nine). In detecting peritoneal metastases and liver metastases, laparoscopy had an accuracy of 92 and 71%, respectively. All patients with vascular or nodal involvement were missed by laparoscopy. For prediction of unresectability disease, the yield and accuracy of laparoscopy were highest for GBC (62% yield and 83% accuracy), followed by IHC (36% yield and 67% accuracy) and HC (25% yield and 45% accuracy) CONCLUSION: Staging laparoscopy ensured that unnecessary laparotomy was not performed in 36% of patients with potentially resectable biliary carcinoma after extensive preoperative imaging. In patients with biliary carcinoma that appears resectable, staging laparoscopy allows detection of peritoneal and liver metastasis in one third of patients. Both vascular and lymph nodes invasions were not diagnosed by this procedure. Due to these limitations, laparoscopy is more useful in ruling out dissemination in GBC and IHC than in HC.
Subject(s)
Biliary Tract Neoplasms/pathology , Laparoscopy , Adult , Aged , Bile Duct Neoplasms/pathology , Bile Ducts, Intrahepatic , Carcinoma/pathology , Cholangiocarcinoma/pathology , Female , Gallbladder Neoplasms/pathology , Humans , Liver Neoplasms/pathology , Liver Neoplasms/secondary , Lymphatic Metastasis/pathology , Male , Middle Aged , Neoplasm Invasiveness/pathology , Neoplasm Staging , Peritoneal Neoplasms/pathology , Predictive Value of TestsABSTRACT
Esophageal diverticula are classified by location-phrenoesophageal (Zenker's diverticulum-70%), thoracic and mediastinal (10%), and epiphrenic (20%). Almost all esophageal diverticula are acquired pulsion diverticula. The most common symptoms are dysphagia, regurgitation, thoracic pain, and pulmonary manifestations related to aspiration. Barium swallow and upper endoscopy will help to establish the diagnosis while esophageal manometry may reveal underlying dysmotility. Diverticula should not be treated unless they are symptomatic. The treatment of Zenker's diverticulum is surgical and consists of either diverticulectomy or diverticular suspension with a myotomy of the cricopharyngeus muscle via cervical approach. Transoral endoscopic stapled diverticulostomy is a new and simple approach which may become the treatment of choice, particularly in elderly and high-risk patients. Treatment of diverticula of the mid and low esophagus must take into account any motor anomalies or associated lesions. Diverticulectomy with esophageal myotomy and an anti-reflux procedure through a left thoracotomy is the standard approach, but endoscopic approaches seem feasible, particularly for epiphrenic diverticula, and may become the norm in years to come.
Subject(s)
Diverticulum, Esophageal , Aged , Diverticulum, Esophageal/classification , Diverticulum, Esophageal/complications , Diverticulum, Esophageal/diagnosis , Diverticulum, Esophageal/diagnostic imaging , Diverticulum, Esophageal/surgery , Endoscopy , Esophagoscopy , Female , Gastroesophageal Reflux/complications , Gastroesophageal Reflux/surgery , Humans , Male , Manometry , Middle Aged , Radiography, Thoracic , Risk Factors , Thoracotomy , Zenker Diverticulum/diagnosis , Zenker Diverticulum/surgeryABSTRACT
The expression and inducibility of four CYP2C genes, including CYP2C8, -2C9, -2C18, and -2C19, was investigated in primary cultures of human hepatocytes. By the use of RNase protection assay and specific antibodies, each CYP2C mRNA and protein were quantified unequivocally. The four CYP2C mRNAs were expressed in human livers and cultured primary hepatocytes, but only the CYP2C18 protein was not detected. Compounds known to activate the pregnane X receptor (PXR) such as rifampicin, or the constitutively activated receptor (CAR) such as phenobarbital, induced CYP2C8, CYP2C9, and to a lesser extent CYP2C19 mRNAs and proteins. CYP2C18 mRNA was expressed but not inducible. The concentration dependence of CYP2C8 and CYP2C9 mRNAs in response to rifampicin and phenobarbital paralleled that of CYP3A4 and CYP2B6, the maximum accumulation being reached with 10 microM rifampicin and 100 microM phenobarbital. In contrast, dexamethasone produced maximum induction of CYP2C8 and CYP2C9 mRNAs at 0.1 microM while in these conditions neither CYP3A4 nor CYP2B6 was significantly induced. Moreover, the concentration dependence of CYP2C8 and CYP2C9 mRNAs in response to dexamethasone paralleled that of tyrosine aminotransferase. Furthermore, dexamethasone, which has been recently shown to up-regulate PXR and CAR expression through the glucocorticoid receptor, potentiated CYP2C8 and CYP2C9 mRNA induction in response to rifampicin and phenobarbital. Collectively, these results suggest the possible implication of at least three receptors in the regulation of CYP2C8 and CYP2C9 expression, i.e., glucocorticoid receptor, PXR, and/or CAR.