Peritoneal implantation of cryopreserved encapsulated porcine hepatocytes in rats without immunosuppression: viability and function.

The bioartificial liver (BAL) represents a promising approach to cell transplantation without immunosuppression as a method to support patients with hepatic insufficiency. The aim of this study was to assess viability and function of cryopreserved encapsulated porcine hepatocytes implanted intraperitoneally in rats without immunosuppression. Isolated porcine hepatocytes were cryopreserved at -196 degrees C for 1 month. Four groups were created: group 1 (n=10), freshly encapsulated porcine hepatocytes cultured in albumin-free medium for 10 days; group 2 (n=10), freshly encapsulated porcine hepatocytes implanted in the rat peritoneum without immunosuppression for 1 month and cultured for 10 days after explantation; group 3 (n=10), cryopreserved encapsulated porcine hepatocytes cultured for 10 days; group 4 (n=10), cryopreserved encapsulated porcine hepatocytes implanted in the rat peritoneum without immunosuppression for 1 month and cultured for 10 days after explantation. We assessed urea and albumin production and hepatocyte viability. The hepatocytes of all groups retained the capacity to produce urea and albumin, although the albumin synthesis was significantly decreased among hepatocytes of group 4 (P< .01). Encapsulated cryopreserved porcine hepatocytes explanted from rat peritoneum after 1 month appeared morphologically viable; their ultrastructure was preserved. In conclusion, long-term cryopreservation of porcine hepatocytes resulted in retention of their biological activity and in significant viability when transplanted into the rat peritoneum without immunosuppression.

Clinical evaluation of fibrin glue in the prevention of anastomotic leak and internal hernia after laparoscopic gastric bypass: preliminary results of a prospective, randomized multicenter trial.

BACKGROUND: Gastro-jejunal anastomotic leak and internal hernia can be life-threatening complications of laparoscopic Roux-en-Y gastric bypass (LRYGBP), ranging from 0.1-4.3% and from 0.8-4.5% respectively. The safety and efficacy of a fibrin glue (Tissucol) was assessed when placed around the anastomoses and over the mesenteric openings for prevention of anastomotic leaks and internal hernias after LRYGBP. METHODS: A prospective, randomized, multicenter, clinical trial commenced in January 2004. Patients with BMI 40-59 kg/m2, aged 21-60 years, undergoing LRYGBP, were randomized into: 1) study group (fibrin glue applied on the gastro-jejunal and jejuno-jejunal anastomoses and the mesenteric openings); 2) control group (no fibrin glue, but suture of the mesenteric openings). 322 patients, 161 for each arm, will be enrolled for an estimated period of 24 months. Sex, age, operative time, time to postoperative oral diet and hospital stay, early and late complications rates are evaluated. An interim evaluation was conducted after 15 months. RESULTS: To April 2005, 204 patients were randomized: 111 in the control group (mean age 39.0+/-11.6 years, BMI 46.4 +/- 8.2) and 93 in the fibrin glue group (mean age 42.9+/-11.7 years, BMI 46.9+/-6.4). There was no mortality or conversion in both groups; no differences in operative time and postoperative hospital stay were recorded. Time to postoperative oral diet was shorter for the fibrin glue group (P = 0.0044). Neither leaks nor internal hernias have occurred in the fibrin glue group. The incidence of leaks (2 cases, 1.8%) and the overall reoperation rate were higher in the control group (P=0.0165). CONCLUSION: The preliminary results suggest that Tissucol application has no adverse effects, is not time-consuming, and may be effective in preventing leaks and internal hernias in morbidly obese patients undergoing LRYGBP.

Laparoscopic subtotal colectomy with cecorectal anastomosis for slow-transit constipation.

Subtotal colectomy with cecorectal anastomosis represents an interesting alternative to total colectomy with ileorectal anastomosis. Several technical variants to the methods for performing the anastomosis between the cecum and the rectal stump after subtotal colectomy have been reported. The mechanical, antiperistaltic, end-to-end cecorectal anastomosis is safe and easy to perform. The authors aimed to assess the safety and feasibility of this technique performed laparoscopically in a series of four patients. All the procedures were completed laparoscopically. The mean time for surgery was 200 min (range, 180-220 min). There was no mortality and no postoperative complications. The mean hospital stay was 4 days (range, 3-5 days). This technique can be performed laparoscopically with all the advantages inherent to the minimally invasive approach.

Laparoscopic repair of chronic intrathoracic gastric volvulus.

BACKGROUND: Totally intrathoracic gastric volvulus is an uncommon presentation of hiatal hernia, in which the stomach undergoes organoaxial torsion predisposing the herniated stomach to strangulation and necrosis. This may occur as a surgical emergency, but some patients present with only chronic, non-specific symptoms and can be treated electively. The aim of this study is to describe a comprehensive approach to laparoscopic repair of chronic intrathoracic gastric volvulus and to critically assess the pre-operative work-up. METHODS: Eight patients (median age, 71 years) underwent complete laparoscopic repair of chronic intrathoracic gastric volvulus. Symptoms of epigastric pain and early satiety were universally present. Five patients had reflux symptoms. The diagnostic evaluation included a video esophagogram, upper endoscopy, 24-hour pH measurement, and esophageal manometry in all patients. Operative results and postoperative outcome were recorded and follow-up at 1 year included a barium swallow in all patients. RESULTS: All patients had documented intrathoracic stomach. Five of 8 patients had a structurally normal lower esophageal sphincter. All 4 patients with reflux esophagitis on upper endoscopy had a positive 24-hour pH study, and 2 of these patients had a structurally defective lower esophageal sphincter on manometry. None of the patients had preoperative evidence of esophageal shortening. All procedures were completed laparoscopically. The procedure included reduction of the stomach into the abdomen, primary closure of the diaphragmatic defect, and the construction of a short, floppy Nissen fundoplication. There were no major complications. One patient required repair of a trocar site hernia 6 months postoperatively. At 1-year follow-up, there were no radiologic recurrences of the volvulus. One patient complained of temporary swallowing discomfort and another had recurrent gastroesophageal reflux disease (GERD) symptoms caused by a breakdown of the wrap. All other patients remained asymptomatic during follow-up. CONCLUSIONS: The repair of chronic gastric volvulus can be accomplished successfully with a laparoscopic approach. A preoperative endoscopy and esophagogram are crucial to detect esophageal stricture or shortening, and manometry is needed to access esophageal motility; pH measurements do not affect operative strategy. The procedure should include a Nissen fundoplication to treat preoperative GERD, to prevent possible postoperative GERD, and to secure the stomach in the abdomen. The procedure is safe but technically challenging, requiring previous laparoscopic foregut surgical expertise.

Gangrene of the perineum.

Fournier's gangrene, an anaerobic necrotizing cellulitis of the infradiaphragmatic soft tissues, is a serious pathologic entity with an unpredictable course. From 1978 to 1991, a total of 24 men (mean age, 57 years; range 27 to 90) were treated for this entity at our institution. Diagnosis prompted immediate institution of multimodal treatment combining triple antibiotics, surgical dissection, debridement, and repeated surgical drainage. Fecal diversion (16 patients), hyperbaric oxygenation, and standard intensive care procedures were widely indicated and performed quasi-systematically. The mean interval between initial symptoms and diagnosis was 7.4 days. Lesions were limited to the perineum in 11 patients but extended to the abdomen, thighs, or loins in the remaining 13. The pathogens were identified in 19 patients, and hemoculture results were positive in 5. A coloproctologic origin was identified in 12 patients and a urogenital origin in 4. In 2 patients, perineal gangrene occurred postoperatively, and no etiology was determined for 6. Six patients died, and 18 patients recovered, without any sequelae. The prognosis is better when the patient is young (less than 60 years old), has clinically localized disease, without systemic involvement, and sterile hemocultures and is managed with colostomy. A thorough workup is mandatory to determine the etiology (locoregional lesion, malignancy, hemopathy, arteritis).

A new technique of surgical treatment of chronic duodenal ulcer without laparotomy by videocoelioscopy.

We performed truncal posterior right vagotomy with lesser curve anterior gastric myotomy by videocoelioscopy on 10 patients (5 men and 5 women, ranging in age from 19 and 54 years, with a mean age of 32 years). All had a long history of chronic duodenal ulcer with a mean duration of symptoms of 3.8 years. The mean length of the operation was 60 minutes (range: 55 to 110 minutes). There was no morbidity, and all patients were discharged after 5 days. The acid secretion tests under basal conditions and under insulin stimulation preoperatively and 1 month postoperatively showed a mean decrease in the basal output of 79.3% and a mean decrease of 83.04% in the maximal output. The fibroscopic control at the second postoperative month showed a complete healing of the ulcer in nine patients and a residual ulcer scar in one. No patients had any abdominal complaints. Right truncal vagotomy and anterior lesser curve seromyotomy by videocoelioscopy is an efficient and elegant method of treating chronic duodenal ulcer, but it needs thorough experimental practice.

The European experience with laparoscopic cholecystectomy.

A retrospective survey of 7 European centers involving 20 surgeons who undertook 1,236 laparoscopic cholecystectomies was performed. The procedure was completed in 1,191 patients. Conversion to open cholecystectomy was necessary in 45 patients (3.6%) either because of technical difficulty (n = 33), the onset of complications (n = 11), or instrument failure (n = 1). There were no deaths reported, and the total postoperative complication rate was 20 of 1,203 (1.6%), with 9 being serious complications requiring laparotomy. The total incidence of bile duct damage was 4 of 1,203. The median hospital stay was 3 days (range: 1 to 27 days) and the median time to return to full activity after discharge was 11 days (range: 7 to 42 days).

Unresolved issues in laparoscopic splenectomy.

BACKGROUND: Laparoscopy is now expanding to surgery of intra-abdominal solid organs such as splenectomy for hematologic diseases. The purpose of this study is to further demonstrate that laparoscopic splenectomy is feasible for the surgeon, teachable for the resident, and beneficial to the patient and to revise prior contraindications to this minimally invasive approach. METHODS: Thirty-three consecutive cases of laparoscopic splenectomy were performed between May 1992 and March 1996. The series included 21 females and 12 males with a median age of 42 years (range 19-79) and a median weight of 73 kg (range 36-115). Indications included: immune thrombocytopenic purpura (20), hemolytic anemia (5), hereditary spherocytosis (4), infarction with abscess (1), Hodgkin's lymphoma (1), Gaucher's disease (1), and AIDS-related thrombocytopenia (1). Dissection was predominately performed with a new surgical instrument, the harmonic shears, and main vessels were controlled with clips. RESULTS: Thirty-two (97%) of the cases were completed laparoscopically, with 1 (3%) conversion to control hilar bleeding. Four patients underwent simultaneous cholecystectomy. The median spleen size was 13 cm (range 8-28) and median weight was 256 g (range 40-2100). Median operating time was 242 minutes (range 85-515). Morbidity occurred in 2 (6%) patients: ileus and small bowel obstruction. Median hospital stay was 4 days (range 2-14). There was no mortality in our series. Median follow-up was 20 months (range 1-46) with no evidence of late surgical complication or recurrent disease. CONCLUSION: Laparoscopic splenectomy may be successful in cases previously considered contraindicated, particularly splenomegaly and splenic infarct with abscess. It is a procedure that can be learned under appropriate guidance in academic centers.

Posterior vagotomy and anterior seromyotomy as elective surgery for duodenal ulcer disease.

BACKGROUND/AIMS: The introduction of acid-reductor drugs in the treatment of duodenal ulcer has led to a drastic reduction in surgical indications. The role of Helicobacter pylori in recurrence and persistence of ulcer has added antibiotics to H2-receptor blockers and proton pump inhibitors. As this triple drug therapy always involves long and short-term side effects and ulcer recurrence is frequent once medication is stopped, surgical treatment with its recognized long-term efficacy has a role to play in prevention of complications. Posterior truncal vagotomy and anterior seromyotomy will guarantee complete denervation of the posterior territory and hence post-vagotomy diarrhea is avoided and motility is maintained in the pyloric and antral regions. METHODOLOGY: Elective posterior vagotomy and anterior seromyotomy was performed on 75 patients (14 F, 61 M) aged 19-61 years with a duodenal ulcer refractory to medical treatment. Sixty-two of them were followed-up for at least 2 years. Vagotomy is performed with the patient in the same position as for cholecystectomy. Five trocars are routinely inserted. The procedure involves three steps: approach for the hiatal region, posterior vagotomy, and anterior seromyotomy. RESULTS: Mean operative time was 140 min (range: 120-220 min). There was no mortality and only one case of pneumothorax which was treated successfully by a chest drainage. As for long-term, one patient developed reflux esophagitis. Fifty-nine patients had healing of their ulcer and 3 other patients had presence of scars 2 months after the operation. Post-operative BAO decreased to 78% and pentagastrin-stimulated acid secretion to 80%. Two pre-pyloric ulcer recurrences occurred 2 years after surgery, which responded to medical therapy. At 2 years, a 65% reduction in both BAO and pentagastrin-stimulated acid secretion was recorded. CONCLUSIONS: Posterior truncal vagotomy with anterior seromyotomy combines the rapidity and effectiveness of truncal vagotomy, which has the advantage of maintaining the gastric antral pump with ultra selective vagotomy. This minimally invasive surgical approach has opened up a new era in effective treatment of ulcer disease, and from now on must represent an alternative to long-term medical therapy.

[Course of the recurrence of hepatitis C virus infection after liver transplantation]. / Evolution de la récidive de l'infection par le virus de l'hépatite C après transplantation hépatique.

OBJECTIVES: Hepatitis C virus recurrence is frequent after orthotopic liver transplantation. The aim of this study was to evaluate the clinical, biological, and histological characteristics of recurrence. METHODS: One hundred and ten patients (91 males, mean age 49 years) with liver transplantation were followed up for more than 1 year (mean: 26 months, range: 12-71). Hepatitis C virus serologic 2nd generation tests were performed before and every 3 months after transplantation in all patients. Serum RNA was detected every 6 months after transplantation by polymerase chain reaction. A percutaneous liver biopsy was performed every year in all patients and in case of abnormal biological liver tests. RESULTS: In 44 patients (40%), hepatitis C virus serology was positive before transplantation, and was unchanged after transplantation. In this group histologic chronic hepatitis was observed in 35 patients (79.5%). The mean Knodell score was 8.4 +/- 2.3, associated with an increase in serum aminotransferases (> twice the upper limit of normal) in 26 cases (74.3%) and with serum RNA in 33 cases (94.3%). The Knodell score was not significantly higher 2 years or more after transplantation than before (9.5 +/- 3.9 vs 7.2 +/- 3.5). In 66 patients with negative hepatitis C virus serology before transplantation, no changes were noted after transplantation. In this group, histologic chronic hepatitis was found in 14 cases (21.2%) associated with serum hepatitis C virus RNA in 7 cases. Actuarial survival rates of the two groups were 97.1% and 91.2% at 2 years, and 93.5% and 86.7% at 5 years, respectively. No death clearly related to hepatitis C virus recurrence was observed. CONCLUSION: Hepatitis C virus recurrence after liver transplantation is frequently associated with chronic hepatitis, and a progressive increase in liver lesions. Nevertheless, the 5-year survival rates was not different in these patients compared to patients with negative hepatitis C virus serology before transplantation.

[Hepatic resection and transplantation for hepatocellular carcinoma in patients with cirrhosis]. / Résection et transplantation hépatique pour carcinome hépatocellulaire chez les malades atteints de cirrhose.

OBJECTIVES: Liver resection and liver transplantation are the only curative treatments for hepatocellular carcinoma in patients with cirrhosis. The aim of this retrospective study was to compare survival and tumor recurrence in patients with cirrhosis after hepatic resection or liver transplantation for hepatocellular carcinoma in patients with cirrhosis. METHODS: Between March 1988 and March 1995, 34 patients underwent liver resection and 30 patients with cirrhosis had liver transplantation for hepatocellular carcinoma. The probability of survival and recurrence were studied according to clinical, biological and pathological factors, defined in liver specimens. Comparisons were performed by the actuarial method and log rank test. RESULTS: Five-year survival after resection and transplantation was 13% and 32.6%, respectively, and 5-year recurrence was 92.6% and 40.9%, respectively (P < 0.01). The diameter of nodules was a significant predictive factor of recurrence in resected patients; the number of nodules was a significant predictive factor in transplanted patients. The combination of these two factors could be used to identify two groups: patients with large carcinoma (diameter > 5 cm and/or number of nodules > 3), and patients with small carcinoma (diameter < or = 5 cm and number of nodules < or = 3). The five-year survival rate of large hepatocellular carcinoma was 17.3% after resection and 0% after transplantation. The five-year survival rate of small hepatocellular carcinoma was 0% after resection and 69.3% after transplantation (P < 0.01). The five-year recurrence of large hepatocellular carcinoma was 72.3% after resection and 100% after transplantation. The five-year recurrence of small hepatocellular carcinoma was 82.6% after resection and 11.1% after transplantation (P < 0.01). CONCLUSIONS: Liver transplantation seems to be the best treatment for small hepatocellular carcinoma, mainly because of a lower recurrence rate. On the other hand, both treatments had a high recurrence rate in large hepatocellular carcinoma.

[Irregular hepatic steatosis. Clinical and imaging study of 6 cases]. / Stéatose hépatique irrégulière. Etude clinique et iconographique de 6 cas.

Irregular fatty infiltration of the liver is an entity that may be confused with liver metastasis. Since ultrasonography and computed tomography of the liver are frequently performed, it seems to be a relatively commonly encountered lesion. The features of this syndrome are described herein in six patients in whom a liver biopsy confirmed diagnosis. Clinical and biological findings were non-specific. In 3 cases ultrasound examination of the liver showed increased echogenic areas. In 3 cases of large lesions, the remaining normal liver was seen as areas of decreased echogenicity and the fatty infiltration was considered falsely normal. The scanographic features of this entity were much more typical than those seen on ultrasonography. With CT, irregular fatty liver usually has a distinctive appearance characterized by a non-spherical shape, absence of mass effect and a density close to water (3 cases). When the fatty lesions are focal (3 cases) and less characteristic on CT, liver biopsy should be performed to confirm the diagnosis. Repeated CT examinations can demonstrate partial or total resolution of the lesions when conditions known to be associated with fatty liver have been treated.

[Recurrence of virus B hepatitis after liver transplantation]. / Récidive du virus de l'hépatite B après transplantation hépatique.

Thirty-three HBs antigen positive patients without signs of viral replication underwent orthotopic liver transplantation and received long term passive immunoprophylaxis with anti-HBs immunoglobulins at high doses perioperatively and then at a dose of 10,000 IU every month. All patients became negative during the first 6 months following surgery. At 34 months the survival rate was 67 percent and the actuarial recurrence rate of serum HBs antigen was 7.1 percent. Reappearance of HBs antigen was associated with evidence of HBV replication and histological alterations of the graft. In our experience, long term passive immunoprophylaxis reduces HBV reinfection of the grafted liver.

[Primary neuroendocrine tumor in the intrahepatic bile ducts: a rare finding in an asymptomatic patient]. / Tumeur neuro-endocrine primitive des voies biliaires intrahépatiques: une découverte exceptionnelle chez un malade asymptomatique.

Neuroendocrine tumors of the biliary tree are rare. In all cases except one, diagnosis was made in symptomatic patients. We report a case of an asymptomatic intrahepatic bile duct neuroendocrine tumor in a 74-year old man. To our knowledge, this is the second reported case of an asymptomatic intrahepatic bile duct neuroendocrine tumor. Diagnosis was only made by anatomopathological examination of the tumor after resection. Systemic and immunohistochemical hormonal screening was negative. Twenty months after surgery, the patient was asymptomatic and there was no recurrence.

Laparoscopic rossetti fundoplication.

A fundal wrap of the abdominal segment of the esophagus, transposed from the Rossetti modification of the classic Nissen fundopfication, is the operation of choice for surgical treatment of gastroesophageal reflux refractory to medical therapy. Previously validated by open anti-reflux surgery, fundoplication has also proven reliable, effective, and reproducible when performed by laparoscopy, a technique the authors have used routinely since 1989 thanks to the experience gained in vagotomy by a trans hiatal approach.

Laparoscopic treatment of peptic ulcer disease and its complications.

Peptic ulcer disease will eventually affect more than 3-4% of the Occidental population. The medical management of this disease, including H2 Blockers, proton pump inhibitors and antihelicobacter therapy, has been well defined and has been very successful. However, the treatment of chronic duodenal ulcer disease has been less successful, thus subjecting these patients to long term disability. It is with chronic duodenal ulcer disease as well as with its complications, such as bleeding, obstruction or perforation, where the surgeon can impact, using laparoscopic surgical techniques as an added therapeutic option.

Laparoscopic management of complications of peptic ulcer disease.

Laparoscopic treatment of intractable duodenal ulcers is intended for the treatment of patients who do not heal after a trial of intensive regimen of medication such as H2 blockers and/or therapy aimed at eradication of Helicobacter pylori. Patients in a category who are Helicobacter-negative can be offered a laparoscopic treatment of their ulcer by vagotomy. Patients who have early relapses on stopping medical treatment are also candidates for vagotomy. Complications of the disease, such as bleeding or pyloric outlet obstruction, represent valid indications in 1995 for performing surgery in patients with duodenal ulcer disease.

Laparoscopic splenectomy.

Several indications for laparoscopic splenectomy are represented mainly by hematological disorders such as Idiopatic Thrombopenic Purpura (ITP) or hereditary spherocytosis. Patients with ITP who do not respond, have relapses of the disease under steroid treatment, or need a gradually increased dose of steroids, represent an excellent indication for laparoscopic splenectomy, as the spleen is not enlarged. Patients are usually small, thin, young females, making the procedure much easier. The size of the spleen in hereditary spherocytosis varies, sometimes making the procedure a little more difficult, especially as those patients have pigmented gallbladder stones necessitating a concurrent laparoscopic cholecystectomy. Other indications are represented by staging of Hodgkin's disease, lymphoma of the spleen, and splenic infarcts without abscesses. Some patients with autoimmune hemolytic anemia might benefit from laparoscopic splenectomy, but hypersplenism due to cirrhosis is strongly contraindicated, as the risk of intraoperative hemorrhage is great and not usually managed easily laparoscopically.

[Biliary complications after a liver transplant]. / Complicanze biliari dopo trapianto epatico.

Biliary tract complications are still an important source of morbidity and mortality after liver transplantation. Between March 1988 and September 1991 we performed 111 liver transplants in 109 patients (84 men and 25 women, mean age 44.5 +/- 1.1 year). Biliary tract reconstruction was via a choledocho-choledochostomy (n = 107) or via a Roux limb choledochojejunostomy (n = 4). Ten biliary complications (11.9%) occurred (6 biliary leakage, 3 biliary strictures, 1 biliary cast syndrome). Five patients (5.9%) necessitated operative repair (Roux limb choledochojejunostomy). No death was related to biliary tract complication.