Luc Michel

Local recurrence after hepatic radiofrequency coagulation: multivariate meta-analysis and review of contributing factors.

Objective:The purpose of this study was to analyze the factors that influence local recurrence after radiofrequency coagulation of liver tumors. Summary Background Data:Local recurrence rate varies widely between 2% and 60%. Apart from tumor size as an important risk factor for local recurrence, little is known about the impact of other factors. Methods:An exhaustive literature search was carried out for the period from January 1, 1990 to January 1, 2004. Only series with a minimal follow-up of 6 months and/or mean follow-up of 12 months were included. Univariate and multivariate meta-analyses were carried out. Results:Ninety-five independent series were included, allowing the analysis of the local recurrence rate of 5224 treated liver tumors. In a univariate analysis, tumor-dependent factors with significantly less local recurrences were: smaller size, neuroendocrine metastases, nonsubcapsular location, and location away from large vessels. Physician-dependent favorable factors were: surgical (open or laparoscopic) approach, vascular occlusion, general anesthesia, a 1-cm intentional margin, and a greater physician experience. In a multivariate analysis, significantly less local recurrences were observed for small size (P < 0.001) and a surgical (versus percutaneous) approach (P < 0.001). Conclusions:Radiofrequency coagulation by laparoscopy or laparotomy results in superior local control, independent of tumor size. The percutaneous route should mainly be reserved for patients who cannot tolerate a laparoscopy or laparotomy. The short-term benefits of less invasiveness for the percutaneous route do not outweigh the longer-term higher risk of local recurrence.

Nutritional Support of Hospitalized Patients

AS limits of nutritional-support programs are tested, the tendency is to simplify regimens for nutrition, to exhaust means of enterai and peripheral-vein supplementation before resorting to central...

Mallory-Weiss syndrome. Evolution of diagnostic and therapeutic patterns over two decades.

During a 19-year period ending December 1978, we treated 40 patients with upper gastrointestinal bleeding secondary to the Mallory-Weiss syndrome. Thirty patients had the triad of vomiting, hematemesis and alcoholism. The presence of lacerations within the gastric cardia was associated with the presence of hiatal hernia (p = 0.03). Endoscopic examinations demonstrated 32 of 38 additional upper gastrointestinal lesions associated with the syndrome that could have been mistaken as the actual source of hemorrhage. During the second decade, as compared with the first decade, widespread use of fiberoptic esophagogastroscopy led to the identification of the bleeding lacerations in 71% of the patients (versus 47% in the first decade) and in 80% (versus 0% in the first decade) of the patients who required an operation to control the bleeding. Although there was a 7.5% mortality rate in the two decades, the incidence of operative treatment tended to decrease (42–24%; p = 0.13). More impressive were the decreases in transfusions (14 units to 5 units per patient) and in delays before surgery (38 hours to 17 hours) (p < 0.05). Improved endoscopic diagnosis facilitates prompt and economic treatment.

Reversal of Biochemical and Functional Abnormalities in Erythrocytes Secondary to Selenium Deficiency

A patient with multiple enterocutaneous fistulae on total parenteral nutrition for 14 months developed low erythrocyte selenium and low erythrocyte glutathione peroxidase. Erythrocyte hexose monophosphate shunt activity stimulated with an H2O2 generating system was approximately one-fourth that of control. Hexose monophosphate shunt activity stimulated with methylene blue showed little difference between patient and control. With selenium supplementation erythrocyte selenium, glutathione peroxidase, and hexose monophosphate shunt activity became normal. Thus, the biochemical and functional consequences of selenium deficiency can be corrected with selenium supplementation.

Bipolar radiofrequency ablation with 2 × 2 electrodes as a building block for matrix radiofrequency ablation: Ex vivo liver experiments and finite element method modelling

Abstract Purpose: Size and geometry of the ablation zone obtained by currently available radiofrequency (RF) electrodes is highly variable. Reliability might be improved by matrix radiofrequency ablation (MRFA), in which the whole tumour volume is contained within a cage of x × y parallel electrodes. The aim of this study was to optimise the smallest building block for matrix radiofrequency ablation: a recently developed bipolar 2 × 2 electrode system. Materials and methods: In ex vivo bovine liver, the parameters of the experimental set-up were changed one by one. In a second step, a finite element method (FEM) modelling of the experiment was performed to better understand the experimental findings. Results:The optimal power to obtain complete ablation in the shortest time was 50–60 W. Performing an ablation until impedance rise was superior to ablation for a fixed duration. Increasing electrode diameter improved completeness of ablation due to lower temperature along the electrodes. A chessboard pattern of electrode polarity was inferior to a row pattern due to an electric field void in between the electrodes. Variability of ablation size was limited. The FEM correctly simulated and explained the findings in ex vivo liver. Conclusions: These experiments and FEM modelling allowed a better insight in the factors influencing the ablation zone in a bipolar 2 × 2 electrode RF system. With optimal parameters, complete ablation was obtained quickly and with limited variability. This knowledge will be useful to build a larger system with x × y electrodes for MRFA.

The rationale for performing MR imaging before surgery for primary hyperparathyroidism

Abstract Objective : The purpose of this study was to evaluate prospectively Magnetic Resonance Imaging (MRI) for the preoperative localization of hyperfunctioning parathyroid glands. Design : Prospective study of 58 consecutive patients with biochemically confirmed primary hyperparathyroidism who underwent preoperative MRI. Setting : The setting is a referral centre. Patients : Fifty-six of the 58 consecutive patients (41 women, 17men) were studied by both preoperative MRI and 99mTC MIBI scintigraphy, and two by MRI alone. The same surgeon, using the information from both MRI and 99mTC MIBI, performed surgery in 58 patients, including 19 with a history of neck surgery. Initial interpretation of each MR study was done independently by one radiologist and the surgeon and then results were compared. At surgery, the operative duration, the precise anatomical location, weight, and dimensions as well as complete histopathological evaluations of all excised glands were recorded. Main outcome measure : In addition to the prospective assessment of MRI, this study compared performance of MRI with double-phase 99mTC MIBI scintigraphy for preoperative localization of hyperfunctioning parathyroid glands. Results : All patients became normocalcaemic after surgery. MRI and 99mTC MIBI imaging revealed 53 of 58 (91%) and 47 of 56 (84%) of abnormal glands, respectively. Sensitivities of MRI and 99mTC MIBI were respectively 94.3 and 88.0. Positive predictive values were 96.15 and 93.60. When MRI and 99mTC MIBI were interpreted together, the sensitivity and positive predictive values both raised to 98.10. Median operative duration was 30 minutes (ranges 20–300 minutes, mean 65). Conclusion : MRI has better sensitivity and positive predictive value than 99mTC MIBI scintigraphy for the detection of hyperfunctioning parathyroid glands. The combination of the two studies provides an additional increase in sensitivity and positive predictive value leading to a more precise anatomical localization of the abnormal parathyroid glands reducing both the extent of the surgical dissection and the operative duration.

Colonic obstruction as a complication of ulcerative colitis

Colonic obstruction requiring specific treatment as a complication of ulcerative colitis occurred in four of 644 patients with ulcerative colitis seem from 1969 through 1979. Four other cases have been reported by others. These obstructions were caused by strictures or pseudopolyps. Although the treatment is nonoperative in some cases, surgery is indicated if carcinoma cannot be ruled out or if obstruction persists.

Painful thyroid nodule, a misleading presentation of subacute thyroiditis

Abstract Typical presentation of subacute thyroiditis (SAT) is an anterior neck pain radiating up to the jaw and ear, often associated with asthenia and fever. Biology shows hyperthyroidism and inflammation. The thyroid uptake is low at scintigraphy. However, the clinical presentation of SAT may be misleading. We report two cases of SAT whose initial manifestation was a painful thyroid nodule suspected of malignancy. In both cases, ultrasound feature was a heterogeneous, hypoechoic, ill-defined area with a low vascularization on colour Doppler. These areas were interpreted by radiologist as nodules. Surgery was then considered. Such a presentation should be known by clinicians to prevent unnecessary surgery.

Handbook of spine surgery - second edition.

The Handbook of Spine Surgery is a comprehensive pocket-size guide that provides the basic principles of modern spine surgery. Throughout 4 main chapters divided into 72 sections, the authors cover the surgical techniques in an easy to consult book, making it a convenient refresher before any spine surgery. The section related to cervical, thoracic and pelvic trauma could have been better developed, namely in the field of associated lesions, and for the choice of priorities in situations in which spinal trauma is only part of multiple traumas (sections 19-21). In this sense, such a textbook would have been a trustworthy companion not only for surgeons caring for patients with spinal disorders but for every trauma surgeons and general surgeons involved in trauma care. Illustrations are clear and numerous, but not in colour. The common clinical questions at the end of each section are enlightening and useful. The answers are provided in a short and direct way. Those questions (and their answers) highlight many of the most frequently encountered clinical problems in this specialized field and/or in the operating theatre during spine surgery.

Robotic Head and Neck Surgery – The Essential Guide

Robotically-assisted surgery is a technological development that use robotic systems to aid surgeon, but not replace him, for minimally-invasive surgical procedures. Indeed, it helps to overcome the limitations bound to limited working space by enhancing the capabilities of surgeons performing surgery in tiny anatomical spaces. In this aspect, robotically-assisted surgery could be of interest for the surgical treatment of head and neck, benign and malignant lesions. The authors of the book demonstrate that state-of-the-art robotics enables surgeons to access those complex anatomical areas using a more minimally invasive approach. The potential to improve patient outcome and reduce surgical morbidity has, however, yet to be proven convincingly. Throughout 16 chapters, the authors provide demonstration of robotic surgical procedures for diseases affecting the oropharynx, larynx, hypopharynx, parapharyngeal space, thyroid, neck and skull base. Videos can be seen online at the editor’s media centre (the access is not very user friendly) complementing the anatomical drawings in the book that are of good quality. Nevertheless, the intraoperative photos are often of rather poor quality and are provided without clear self-explanatory legends. Concerning chapter 3 related to the ethics of surgical innovation, the discussion about the basic question ‘‘Is New Better?’’ is biased, too short, and does not take into account the fact that, as innovations are highly valued in our societies, they also raise several moral issues which are not addressed in this essential guide of robotic head and neck surgery; not even the conflict of interests issue created by the development and application of innovations.[1] For instance, we all know that the term ‘‘innovation’’ has a seductive connotation of added value in our market society. There is even a class of patients psychologically disposed to seek innovative treatment because it is the latest and, sometimes by erroneous inference, the best available. In surgical practice, however, the patient’s preference is not the final word, although patients’ attitudes and behaviour are tending more and more toward the consumers.[2] Therefore, to declare in the light of the South Korea experience,[3] that robotic thyroidectomy with modified radical neck dissection (MRND) was found to enhance quality of life, and outcomes relative to conventional open thyroidectomy with MRND is not substantiated by data, but above all it questions the level of surgical skills with the open approach by the proponents of the robotic-assisted thyroidectomy. Furthermore, the authors provide Figure 13–7 as an example of terrible neck scars obtained after open thyroidectomy as a definitive argument in favour of the transaxillary robotic thyroidectomy giving supposedly excellent cosmetic satisfaction. First of all, the open approach by expert endocrine surgeon can give excellent cosmetic results with postoperative scars; cosmetic results after robotic surgery can sometimes be terrible too. To remove a cancer of the thyroid through a transaxillary approach is anything but minimallyinvasive surgery. In addition, it is contrary to basic principles of surgical oncology. Although the selective set of data presented suggest that the completeness of the robotic thyroidectomy is similar to conventional thyroidectomy, the follow-up time has been too short to truly assess the oncologic outcome.[4] Many questions remain: for example, is the robotic transaxillary thyroidectomy cost effective? What guidelines should be used for training a surgeon to use this approach? What is the long-term outcome for clinically significant thyroid cancer? Are many patients likely to be candidates for this approach?[4] For example, patients in Europe and the United States have larger body habitus and higher body mass index than those in South Korea.[5,6] What new complications, and at what rate, would we observe if this approach rapidly proliferates in clinical practice? Some degree of modesty in Surgery is always a good long-term investment especially for a new textbook.