Showing papers by "René Adam published in 2002"

A Comparison of Percutaneous Cryosurgery and Percutaneous Radiofrequency for Unresectable Hepatic Malignancies

Abstract: Hypothesis The complication and success rates in patients treated with either percutaneous cryosurgery (PCS) or percutaneous radiofrequency (PRF) for unresectable hepatic malignancies are similar. Design Retrospective study. Setting University hospital. Patients and Methods Sixty-four patients were treated with either PCS (n = 31) or PRF (n = 33). Patient treatment was based on the random availability of the probes. Tumors were evaluated by a blinded comparison of pretreatment and posttreatment helical computed tomographic scans. All living patients had at least a 6-month follow-up. Main Outcome Measures Complication rate, initial treatment success (complete devascularization of the tumor), and local recurrence (tumor revascularization within or at its periphery). Results The distribution of tumor types was similar in the 2 groups ( P = .76). One patient with cirrhosis died of variceal hemorrhage on day 30 after PCS (mortality, 3.2%), while no mortality was observed after PRF ( P = .48). Complications occurred in 9 (29%) of the patients following PCS and in 8 (24%) of the patients following PRF ( P = .66). Initial treatment success was comparable in the 2 treatment groups (30 [83%] of 36 tumors following PCS vs 34 [83%] of 41 tumors following PRF). However, local recurrences occurred more frequently after PCS than after PRF (16 [53%] of 30 vs 6 [18%] of 34; P = .003). The higher rate of local recurrence was identified for metastases (10 [71%] of 14 after PCS vs 3 [19%] of 16 after PRF; P = .004), while the difference was not significant for hepatocellular carcinoma (6 [38%] of 16 after PCS vs 3 [17%] of 18 after PRF; P = .25). Multivariate analysis demonstrated that the use of PCS ( P = .003) and more than 1 treatment ( P = .05) were independent risk factors for local tumor recurrence. Conclusion While similar initial treatment success and complication rates are observed following either PCS or PRF, local recurrences occur more frequently following PCS, particularly for metastases.

Decision for retransplantation of the liver: an experience- and cost-based analysis.

Abstract: Liver retransplantation is the only therapy for irreversible graft failure and represents 10% to 22% of transplantation activity worldwide 1–10 (Table 1). With the introduction of cyclosporine, liver retransplantation initially played a role in the improvement of survival of liver transplantation. 11,12 Since then, retransplantation has been repeatedly associated with lower survival rates than first transplantation. 1,3,4,12–15 The medical problem is compounded by financial and ethical issues since retransplantation is costly and denies access to transplantation to patients awaiting their first transplant. 3,4,6,16,17 Table 1. RETRANSPLANTATION RATE, OPERATIVE MORTALITY, AND REPORTED LONG-TERM SURVIVAL (SERIES >30 CASES) Practically, the decision regarding retransplantation rests on two considerations: the operative risk of retransplantation and the chance of long-term survival. Most reports quote perioperative and donor factors as predictors of prognosis when, in fact, these data are not available when listing a patient for retransplantation. The objective of the present study was to identify factors available at the time of decision of retransplantation, thus excluding intraoperative and donor data, with prognostic value for short- and long-term survival, by studying a series of 139 consecutive cases of retransplantation in a single unit.

Neurological improvement during bioartificial liver sessions in patients with acute liver failure awaiting transplantation.

Abstract: BACKGROUND Brain edema is the main cause of death in acute liver failure patients awaiting transplantation. We assessed the HepatAssist 2000, a liver-assist system containing porcine hepatocytes, as a bridge to transplantation in patients with acute liver failure. METHODS Thirteen patients suffering from acute liver failure with criteria for transplantation entered an open baseline-controlled study, with liver-assist treatment sessions at 24-hr intervals until transplantation. Neurological status was regularly evaluated using the Glasgow Coma Scale. RESULTS Three patients were not treated: one had an immediate transplantation and two improved spontaneously. Ten patients received one to three courses of HepatAssist. A significant neurological improvement (mean Glasgow Coma Scale before and after treatment: 6.5+/-3.7 and 9.6+/-4.4, respectively, P<0.02) was observed, which was related to the volume of plasma processed per square meter of body surface. A significant decrease was observed in mean levels of bilirubin (P=0.0005) and transaminases but not in the other indicators of liver function. Six patients had transient episodes of hemodynamic instability, and five had bleeding complications. Two patients died after transplantation. Eight patients survived with a mean follow-up of 24.3 (18-32) months. CONCLUSION The HepatAssist 2000 is well tolerated, improves cerebral function, and may be used as a bridge to transplantation for patients with liver failure.

[Liver transplantation with cavoportal or renoportal anastomosis: a solution in cases of diffuse portal thrombosis].

Abstract: Objectif - La thrombose diffuse du systeme porte etait une contre-indication formelle de la transplantation hepatique jusqu'a l'utilisation recente des techniques de reperfusion portale du greffon par le sang cave inferieur. Les resultats a distance de notre experience de ces techniques sont rapportes ici. Malades et methodes - Huit malades avec thrombose portale diffuse ont ete transplantes avec une reperfusion portale par anastomose latero-terminale entre la veine cave native (2 malades) ou termino-terminale entre la veine renale gauche native (6 malades) et le tronc porte du greffon. Resultats - Trois malades sont decedes 3, 3 et 6 mois apres la transplantation d'hemorragie cerebrale, d'arret cardiaque et de rejet chronique respectivement. Trois malades ont eu des complications d'hypertension portale apres la transplantation. Cinq malades sont vivants a domicile avec un recul median de 9 mois (de 2 a 37 mois) avec des fonctions hepatique et renale, une hemodynamique portale et une histologie hepatique normales. Conclusion - La reperfusion portale du greffon hepatique par le sang cave permet la transplantation jusqu'a present recusee des malades avec thrombose portale diffuse. Des arguments en faveur de l'anastomose reno-porte sont apportes par notre experience et par l'analyse de la litterature.

[Liver transplantation for intrahepatic Rendu-Osler-Weber's disease: the Paul Brousse hospital experience].

Abstract: Neuf centres ont rapporte 15 cas de transplantation hepatique pour maladie de Rendu-Osler-Weber avec atteinte hepatique. Six cas sont rapportes ici afin d'en analyser les aspects techniques et hemodynamiques specifiques. Malades et methodes - Cinq femmes et 1 homme ont ete transplantes pour maladie de Rendu-Osler-Weber. Le tableau predominant etait une maladie biliaire dans 3 cas, une hypertension portale dans 2 cas et une insuffisance cardiaque dans 1 cas. L'hemodynamique systemique etait mesuree par sonde de Swann-Ganz en debut et en fin de transplantation. Resultats - La transplantation necessitait la transfusion de 16 a 88 culots globulaires (mediane = 59 culots) et durait de 11 a 15 heures (mediane = 13 heures et 15 minutes). Les 6 malades avaient un syndrome hyperkinetique en debut d'intervention. En fin d'intervention, on observait une augmentation significative de la pression arterielle moyenne (de 66 ± 2 a 72 ± 6 mm Hg, p < 0,05), et une diminution significative du debit cardiaque (de 9,2 ± 3 a 5,7 ± 0,5 L/mn, p < 0,05). Deux malades sont decedes a J2 et J11 et quatre sont vivants 3 a 7,5 ans (mediane = 4 ans 9 mois) apres transplantation avec une fonction hepatique normale et sans symptomatologie cardio-vasculaire. Conclusion - La transplantation pour maladie de Rendu-Osler-Weber est une intervention difficile. En cas de succes, elle est curative sur l'hepatopathie et le syndrome hyperkinetique.

Combined effects of fasting and alanine on liver function recovery after cold ischemia.

Abstract: The effect of donor nutritional status on hepatic function recovery after cold ischemia is still debated. We demonstrated previously that a 48-h fast diminished the survival rate of liver-transplanted rats and that the deleterious effect of fasting was prevented by infusion of alanine to the recipient at reperfusion. Whether the duration of fasting influenced the protective effect of alanine and whether this effect was metabolic were not known, and the elucidation of these questions is the aim of this study. The effect on hepatic function recovery of fasting periods of 24 h, 48 h and 72 h prior to cold ischemia were studied in a model of isolated, perfused rat liver. After a cold-ischemic time of 24 h in University of Wisconsin (UW) solution at 4°C, livers were reperfused for 3 h. The combined effect of alanine (8 mM) infusion at liver reperfusion was evaluated for each prior fasting period. The addition of pyruvate (8 mM), a metabolic intermediary of alanine, was only tested in the 72-h fasting group. The evaluation criteria were: liver weight after reperfusion, release of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and lactate dehydrogenase (LDH) in the perfusate, bile production, vascular resistance and liver histology after reperfusion. The enzyme release at reperfusion was significantly higher when livers were harvested from rats submitted to a 48-h fast (ALT) or a 72-h fast (ALT, AST, LDH), as compared to those from fed rats. Vascular resistance was increased in 72-h fasted livers. An addition of alanine (8 mM) at reperfusion lowered the release of AST, ALT and LDH. This effect was more obvious when the fasting duration was increased. By contrast, the addition of pyruvate at reperfusion did not improve the recovery of livers submitted to a 72-h fasting period before preservation. A long fasting period is deleterious as compared to feeding; however, this effect can be compensated by infusion of alanine at reperfusion. The mechanism involved is not metabolic. In a clinical setting, the infusion of alanine to the recipient at reperfusion may be a convenient way to compensate for donor undernutrition, especially after a long stay in an intensive care unit.

Long-Term Results of Transplantation for Hepatocellular Carcinoma With or Without Cirrhosis: 15 Years’-Experience at Paul Brousse Hospital

Abstract: Hepatocellular carcinoma (HCC) still remains a controversial indication for liver transplantation (LT) An evaluation of long-term results is mandatory to define the patients who are likely to benefit from cadaveric or living-related LT During 15 years’ experience, 220 LTs were performed consecutively at a single institution for HCC in patients with or without underlying cirrhosis (195 and 25 cases, respectively) The patients were younger and the proportion of females was higher in the noncirrhotic group (P < 0001) Perioperative mortality (≤2 months) was 4% in cirrhotic and 0% in non cirrhotic patients In spite of a higher incidence of recurrence related to more extensive tumors in HCC without cirrhosis (54% vs 20%, P < 0001), survival after transplantation was similar: 60% and 48% at 5 and 10 years, respectively, for patients without cirrhosis, and 73% and 39%, respectively, for patients with underlying cirrhosis (P not significant) While the combination of size and number of tumors was highly predictive of recurrence and survival in the cirrhotic group, this was not the case for non-cirrhotic patients However, portal invasion was poorly associated with survival in both groups HCC with and without underlying cirrhosis represents two separate entities with different patterns of evolution The criteria of selection for transplantation should follow different policies in these two groups of patients