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Liver cysts and abcesses. Liver cysts are common lesions and present in around 5% of the population. Their diagnosis is based on clinical presentation and imaging, mostly ultrasound and computed-tomography- scan. Magnetic resonance imaging and contrast-enhanced ultrasound are useful in order to characterize complex or atypical cystic lesions. The simple hepatic cyst is the most common lesion; it is always benign and is usually asymptomatic. It does justify neither monitoring nor treatment. The other cystic lesions of the liver are of infectious origin: the hydatid disease, caused by Echinococcus and frequent in endemic areas, and hepatic abscesses that include pyogenic and amebic abscesses. Other rare cystic lesions include mucinous cystic lesions, which have vascularized solid components and are potentially malignant, and cystic metastases. Overall, less than 5% of cystic liver lesions are malignant.Kystes et abcès hépatiques. Les lésions kystiques hépatiques sont fréquentes, observées dans environ 5 % de la population générale. Leur diagnostic repose sur la présentation clinique et leur caractérisation est principalement faite par échographie et tomodensitométrie injectée. Pour identifier les lésions kystiques hépatiques complexes ou atypiques, l’imagerie par résonance magnétique et plus récemment l’échographie de contraste peuvent être utiles. Le kyste biliaire, toujours bénin, est de loin la lésion la plus fréquente. Généralement asymptomatique, il ne nécessite pas de traitement ni de surveillance. Les autres lésions kystiques hépatiques sont représentées par les étiologies infectieuses : le kyste hydatique, d’origine parasitaire, assez fréquent surtout dans les régions d’endémie, et les abcès hépatiques, regroupant les abcès à pyogènes et les abcès amibiens. Très rarement, il s’agit de tumeurs kystiques mucineuses ayant des parois et des végétations vascularisées et pouvant dégénérer, ou de métastases kystiques. Au total, moins de 5 % des lésions kystiques hépatiques sont des tumeurs malignes.

La pancreatite cronica e una malattia infiammatoria cronica del pancreas caratterizzata da dolore, fibrosi del parenchima e insufficienza pancreatica. Il dolore cronico o acuto ripetuto resistente al trattamento medico e/o endoscopico massimale e l’indicazione principale della derivazione chirurgica wirsungodigiunale su ansa a Y. La derivazione e preferita alle resezioni pancreatiche, che possono essere tecnicamente difficili e indurre o aggravare un’insufficienza pancreatica. Le tecniche di derivazione del dotto di Wirsung (derivazione wirsungodigiunale semplice e intervento di Frey, di Beger o di Izbicki) permettono di decomprimere il dotto di Wirsung risparmiando completamente la funzionalita pancreatica. Oltre al suo effetto analgesico, che e ben stabilito, la decompressione del dotto di Wirsung potrebbe rallentare la progressione dell’insufficienza pancreatica. Tranne che per l’intervento di Izbicki, tutte le derivazioni richiedono la presenza di una dilatazione del dotto pancreatico. Possono essere associate delle derivazioni biliari, digestive o di pseudocisti. Queste derivazioni sono, talvolta, tecnicamente difficili in certi malati per via dell’ipertensione portale segmentaria indotta dalla trombosi splenica o dall’ipertensione dell’asse mesentericoportale. Un approccio laparoscopico e possibile in caso di derivazione wirsungodigiunale semplice. La mortalita della derivazione wirsungodigiunale e quasi nulla e la morbilita e debole; la principale morbilita e polmonare, legata al consumo di tabacco. I risultati in termini di dolore sono buoni nell’80% dei casi o piu a seconda della tecnica utilizzata, ma e possibile una recidiva dolorosa probabilmente a causa dei meccanismi ancora non perfettamente noti del dolore nella pancreatite cronica.

La pancreatitis cronica es una enfermedad inflamatoria cronica del pancreas que se caracteriza por la presencia de dolor, una fibrosis del parenquima e insuficiencia pancreatica. El dolor cronico o agudo recidivante y refractario al tratamiento medico y/o endoscopico es la indicacion principal de la derivacion quirurgica Wirsung-yeyunal en un asa en Y. Se prefiere realizar una derivacion en lugar de resecciones pancreaticas, que pueden ser tecnicamente dificiles e inducir o agravar una insuficiencia pancreatica. Las tecnicas de derivacion del conducto de Wirsung (derivacion Wirsung-yeyunal simple, intervencion de Frey, intervencion de Beger o de Izbicki) permiten descomprimir el conducto de Wirsung, respetando simultaneamente la funcion pancreatica. Ademas de su efecto antalgico, que esta bien demostrado, la descompresion del conducto de Wirsung podria ralentizar la progresion de la insuficiencia pancreatica. A excepcion de la intervencion de Izbicki, todas estas derivaciones requieren la presencia de una dilatacion del conducto pancreatico. Se les pueden asociar derivaciones biliares, digestivas o de seudoquistes. Estas derivaciones son dificiles en ocasiones desde el punto de vista tecnico en algunos pacientes, debido a la hipertension portal inducida por la trombosis esplenica o del eje mesentericoporta. Se puede realizar un acceso laparoscopico en caso de derivacion Wirsung-yeyunal simple. La mortalidad de la derivacion Wirsung-yeyunal es casi nula y la morbilidad es baja; la principal morbilidad es pulmonar, relacionada con el tabaquismo. Los resultados en terminos de dolor son buenos en el 80% de los casos o mas, dependiendo de la tecnica utilizada, pero puede producirse una recidiva dolorosa, debida probablemente a mecanismos aun no bien conocidos del dolor en la pancreatitis cronica.

Splenectomy is attended by medical complications, principally infectious and thromboembolic; the frequency of complications varies with the conditions that led to splenectomy (hematologic splenectomy, trauma, presence of portal hypertension). Most infectious complications are caused by encapsulated bacteria (Meningococcus, Pneumococcus, Hemophilus). These occur mainly in children and somewhat less commonly in adults within the first two years following splenectomy. Post-splenectomy infections are potentially severe with overwhelming post-splenectomy infection (OPSI) and this justifies preventive measures (prophylactic antibiotics, appropriate immunizations, patient education) and demands prompt antibiotic management with third-generation cephalosporins for any post-splenectomy fever. Thromboembolic complications can involve both the caval system (deep-vein thrombophlebitis, pulmonary embolism) and the portal system. Portal vein thrombosis occurs more commonly in patients with myeloproliferative disease and cirrhosis. No thromboembolic prophylaxis is recommended apart from perioperative low molecular weight heparin. However, some authors choose to prescribe a short course of anti-platelet medication if the post-splenectomy patient develops significant thrombocytosis. Thrombosis of the portal or caval venous system requires prolonged warfarin anticoagulation for 3 to 6 months. Finally, some studies have suggested an increase in the long-term incidence of cancer in splenectomized patients.

Summary Background Supra-mesocolic surgery (SMS) is complicated in patients with portal vein cavernoma (PC) and portal decompression is recommended. The aim of this study was to report a large single centre of SMS in patients with PC without portal decompression. Methods Between 2006 and 2013, all patients who met inclusion criteria were analyzed retrospectively. The primary endpoint was the feasibility rate, surgical and postoperative outcome. The secondary endpoints were the long-term outcome of patients who underwent biliary bypass for cholangitis. Risk factors for complications were studied. Results Thirty patients underwent 51 procedures. Pancreatitis was the main etiology of PC (19/30) and biliary obstruction was mainly related to the underlying disease and not to portal cholangiopathy (12/14). All planned procedures were successfully completed. Fourteen patients underwent biliary bypass. Median blood loss (250 ml), transfusion (n = 7), mortality (n = 0), overall morbidity (n = 12) and the median hospital stay (10 days). Good long-term control of cholangitis was achieved in the 9 patients alive with available follow-up. Significant risk factors for complications were a previous abdominal wall scar, previous intra-abdominal surgical field and liver fibrosis. Conclusion SMS can be safely performed in patients with PC. In patients with risk factors for complications, portal decompression should be discussed.

To determine accuracy of 2012 International Consensus Guidelines (ICG) predicting malignancy in a surgical cohort of branch-duct intraductal papillary mucinous neoplasms (BD-IPMN).This study included all consecutive patients with final pathological diagnosis of pure BD-IPMN resected between 2006 and 2014 at Beaujon Hospital. Neoplasms were classified as malignant in presence of high-grade dysplasia (HGD) or invasive carcinoma. Medical, pathological, and radiological data were retrospectively recorded.One hundred and twenty patients (65 males, mean age: 57.9 ± 10.8 years) were included. Malignant BD-IPMN accounted for 30% (HGD: 18%, invasive: 12%). Thickened cyst walls (odds ratio (OR): 3.058, 95% confidence interval (CI 95%): 1.102-8.484, p = 0.032), main duct diameter 5-9 mm (OR: 3.395, CI 95%: 1.349-8.543, p = 0.007), and mural nodule (OR: 3.802, CI 95%: 1.156-12.511, p = 0.028) were independently associated with malignancy in multivariate analysis. Among the 89 patients (74%) who underwent surgical resection with ICG criteria, the malignancy rate was 38%, compared with 6% in the 31 ICG-negative group. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for malignancy of having at least one ICG criteria were 94%, 34%, 38%, 94%, and 53%, respectively. Patients with malignant tumors had more ICG criteria than those with benign lesions (2.06 ± 0.98 vs. 0.99 ± 0.95, p 0.001).2012 ICG criteria are useful to manage BD-IPMN permitting not to miss a malignant form (NPV of 94%), but frequently point out unnecessary surgery (PPV of 38%). Malignancy rate increases with the number of ICG criteria. In patients with only one criterion, additional criteria would be necessary.

Background Solid pseudopapillary neoplasms of the pancreas (SPPN) can relapse very late, but little is known about risk factors for recurrence and optimal treatment. We aimed to identify risk factors for recurrence and to analyze treatment modalities in all French pediatric cases of SPPN over the past 20 years. Material and methods Data were collected from pediatric oncologists and surgeons, and also from adult pancreatic surgeons in order to identify late recurrences. Results Fifty-one patients (41 girls) were identified. Median age at diagnosis was 13.1 years [8.7–17.9]. Abdominal pain was the commonest presenting symptom (32/49, 65%). The tumor was located in the pancreatic head in 24 patients (47%). Preoperative biopsy or cytology was performed in 14 cases (28%). All patients were operated with a median of 23 days [0–163] after diagnosis. The rate of postoperative morbidity was 29%. With a median follow-up of 65 months [0.3–221], the overall and event-free survival was 100% and 71%, respectively. Seven patients (13.7%) relapsed with a median of 43 months [33–94] after initial surgery. Six were treated surgically, either alone (n = 3) or with perioperative chemotherapy (n = 2) or hyperthermic intraperitoneal chemotherapy (n = 1). One patient in whom further treatment was not feasible was still alive at last news. Risk factors for recurrence were positive surgical margins (P = 0.03) and age less than 13.5 years at diagnosis (P = 0.03). Conclusions SPPN recurrence in this pediatric series was a rare and late event that did not undermine overall survival. Complete surgical removal of recurrent tumors appears to be the best option.

Early biliary complications (EBC) following pancreaticoduodenectomy (PD) are poorly known. This study aimed to assess incidence, predictive factors, and treatment of EBC including bilio-enteric stricture, transient jaundice, biliary leak, and cholangitis.From 2007 to 2011, 352 patients underwent PD. Statistical analysis including logistic regression was performed to determine EBC predictive factors.49 patients (14%) developed 51 EBC, including 7(2%) bilio-enteric strictures, 15(4%) transient jaundices, 9(3%) biliary leaks, and 20(6%) cholangitis with no mortality and a 18% reoperation rate. In multivariate analysis, male gender, benign disease, malignancy with preoperative chemoradiation, and common bile duct (CBD) diameter ≤ 5 mm were predictive of EBC. Of the 7 strictures, all were associated with CBD ≤ 5 mm and 5(71%) required reoperation. Transient jaundice resolved spontaneously in all 15 cases. Among 8 patients with serum bilirubin level50 μmol/L (3 mg/dL) at POD3, 7(88%) developed bilio-enteric stricture. Biliary leak resolved spontaneously in 5(56%); otherwise, it required reoperation. Cholangitis recurred after antibiotics discontinuation in 5(25%).EBC following PD do not increase mortality. EBC are more frequent with male gender, benign disease, malignancy with preoperative chemoradiation, and CBD ≤ 5 mm. Transient jaundice or cholangitis has a favorable outcome, whereas bilio-enteric stricture or biliary leak can require reintervention.

Summary Introduction Following publication of improved patients’ outcome using first line FOLFIRINOX for metastatic pancreatic adenocarcinoma, many physicians now prescribe it as neo-adjuvant or induction treatment for borderline and locally advanced pancreatic cancer. A pathologic complete response, rarely seen with previous preoperative regimens, is sometimes observed in these patients. The aim of this study was to assess long-term outcomes of patients presenting pathologic complete response after preoperative FOLFIRINOX usually followed by chemo-radiation therapy for non-metastatic pancreatic adenocarcinoma. Material and methods We retrospectively identified all resected patients with pancreatic cancer presenting pathologic complete response after FOLFIRINOX in 9 French centers from the AGEO group between November 2010 and May 2017. Results 29 patients were enrolled, 14 had borderline, 14 locally advanced and 1 oligo-metastatic pancreatic cancer. M/F ratio was 1.2 and the mean age was 57 years. All patients were treated with FOLFIRINOX (n = 29), de-escalated to gemcitabine (n = 1) and FOLFIRI (n = 2), and 24 (83 %) received radiation therapy after chemotherapy. Objective response rate to preoperative chemotherapy was 66% (RECIST V1.1). Only 8 patients received postoperative chemotherapy. After a median follow-up of 34 months from surgery, the median overall survival was not reached and the median disease free survival was 48 months. The 1-year and 2-year survival rates were 100% for OS and 96% and 72 % for DFS from surgery, 8 of the 9 observed recurrences were distant metastases. Conclusions The promising 1 and 2-year overall survival and disease free survival rates suggest that pathologic complete response is a major prognostic factor in resected pancreatic cancer following preoperative chemo-radiotherapy. A longer follow-up and prospective series are now necessary to confirm these encouraging results and to potentially validate pathologic complete response as a relevant surrogate marker of preoperative treatment efficacy.

The current paradigm in the pathogenesis of several hemolytic red blood cell disorders is that reduced cellular deformability is a key determinant of splenic sequestration of affected red cells. Three distinct features regulate cellular deformability: membrane deformability, surface area-to-volume ratio (cell sphericity), and cytoplasmic viscosity. By perfusing normal human spleens ex vivo, we had previously showed that red cells with increased sphericity are rapidly sequestered by the spleen. Here, we assessed the retention kinetics of red cells with decreased membrane deformability but without marked shape changes. A controlled decrease in membrane deformability (increased membrane rigidity) was induced by treating normal red cells with increasing concentrations of diamide. Following perfusion, diamide-treated red blood cells (RBCs) were rapidly retained in the spleen with a mean clearance half-time of 5.9 minutes (range, 4.0-13.0). Splenic clearance correlated positively with increased membrane rigidity (r = 0.93; P < .0001). To determine to what extent this increased retention was related to mechanical blockade in the spleen, diamide-treated red cells were filtered through microsphere layers that mimic the mechanical sensing of red cells by the spleen. Diamide-treated red cells were retained in the microsphilters (median, 7.5%; range, 0%-38.6%), although to a lesser extent compared with the spleen (median, 44.1%; range, 7.3%-64.0%; P < .0001). Taken together, these results have implications for understanding the sensitivity of the human spleen to sequester red cells with altered cellular deformability due to various cellular alterations and for explaining clinical heterogeneity of RBC membrane disorders.

Although splenectomy is recommended during resection for left-sided resectable pancreatic ductal adenocarcinoma (PDAC) to perform lymphadenectomy of station 10 (splenic hilum), no level I evidence justifies this procedure. This study aims to evaluate the rate of lymph node (LN) and contiguous involvement of the splenic hilum in resectable distal PDAC. We retrospectively reviewed all patients who underwent splenopancreatectomy for PDAC in the past 10 years. Station 10 LN were routinely isolated, and all corresponding microscopic slides were reinterpreted by a pathologist. The computed tomography (CT) results of patients with tumoral involvement of the spleen or splenic hilum by contiguity (TISOSH) and ≤ 10 mm between the tumor and spleen on pathology were blindly reviewed by two radiologists to evaluate CT for diagnosis of TISOSH. We included 110 consecutive patients, including 104 with analyzable station 10 LN. The tumor was N+ in 58 (53%) patients. The median number of LN identified at station 10 was 2.0 ± 3.0. No station 10 LNs were detected in 42 (40%) patients. No patients had tumor-positive LN at station 10. TISOSH was found in nine (8%) patients, and was significantly associated with tail location (p = 0.001), tumor size (p = 0.005), and multivisceral involvement (p = 0.015). For diagnosis of TISOSH, the sensitivity and specificity of CT were respectively 89% and 95% for radiologist 1 and 89% and 100% for radiologist 2. Splenic preservation during resection of distal PDAC may be an option in selected patients with body tumors and no suspected splenic or splenic hilum involvement on preoperative CT.

Background: Gastric traction is essential in laparoscopic distal pancreatic resections. We already described the single gastric hanging providing good exposure on the left pancreas and we herein introduce a modification named the double gastric hanging. Methods: The double gastric hanging in which 2 surgical tapes encircle the body and antrum of the stomach is indicated in patients who requiring pancreatic neck resection, dissection along the celiac trunk collaterals and lymph nodes, the duodenal wall, and the gastroduodenal artery. We describe our surgical technique, we compare our results between the double and single gastric hanging and we illustrate by 2 shorts videos for distal pancreatectomy and central pancreatectomy. Results: Between September 2016 and December 2017, this technique was performed in 36 patients who underwent central pancreatectomy (n = 18), distal pancreatectomy (n = 14), and enucleation (n = 4). There was no conversion, no transfusion, no mortalities, and no gastric related complications or reinterventions. Although not significant, the double gastric hanging and compared to single gastric hanging showed more favorable operative results with shorter operative time, less blood loss, and higher number of harvested lymph nodes. In patients operated for pancreatic adenocarcinoma, the mean number of harvested lymph nodes was higher with the double gastric hanging (23 vs. 14, p = 0.027). Conclusion: The double gastric hanging provides excellent exposure of the pancreatic neck, celiac trunk collaterals, and lymph nodes for better technical and oncological resections with no related complications.

Item does not contain fulltext BACKGROUND: In collaboration with United European Gastroenterology, the working group on 'Harmonizing diagnosis and treatment of chronic pancreatitis across Europe' (HaPanEU) developed European guidelines for the management of chronic pancreatitis using an evidence-based approach. METHODS: Recommendations of multidisciplinary review groups based on systematic literature reviews to answer predefined clinical questions are summarised. Recommendations are graded using the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS: Recommendations covered topics related to the clinical management of chronic pancreatitis: aetiology, diagnosis of chronic pancreatitis with imaging, diagnosis of pancreatic exocrine insufficiency, surgical therapy, medical therapy, endoscopic therapy, treatment of pancreatic pseudocysts, pancreatic pain, nutrition and malnutrition, diabetes mellitus and the natural course of the disease and quality of life. CONCLUSIONS: The HaPanEU/United European Gastroenterology guidelines provide evidence-based recommendations concerning key aspects of the medical and surgical management of chronic pancreatitis based on current available evidence. These recommendations should serve as a reference standard for existing management of the disease and as a guide for future clinical research. This article summarises the HaPanEU recommendations and statements.

In the original article, the institutional author the E-AHPBA DP-CAR study group was misspelled. It is correct as reflected here. The original article has also been corrected.

Background Cancer-associated acute cholangitis (CAAC) are becoming more frequent and their characteristics may be changing with the evolution of cancer management. Our aim was to compare clinical, microbiological and outcome characteristics of CAAC to those of cancer-free acute cholangitis (CFAC). Methods All consecutive cases of acute cholangitis (AC) from November 2015 to March 2017 were collected retrospectively in a single tertiary care hospital in Clichy, France, specialized in gastroenterology. Hospital stays referred as AC by coding were screened. Patients fulfilling the 2018 Tokyo Guidelines diagnostic criteria for definite AC were included. Data were collected using a standardized form. CAAC were defined as AC that occurred in patients who had active cancer or history of cancer in the five previous years. CFAC were defined as AC in patient who no history of cancer, or in remission for more than 5 years. Comparison was made using Fisher or Student’s t-test. P < 0.05 was considered as significant. Results 156 episodes of AC in 130 patients were analyzed. 101 had CAAC and 55 had CFAC. Age and sex did not differ (table 1), but CAAC had a higher Charlson’s comorbidity index (4.4 vs. 1.7, P < 0.0001). Despite similar clinical presentation, CAAC had more pronounced cholestasis (Gamma GT 659 vs. 391UI/L; Alkaline phosphatases 526 vs. 309 UI/L; P < 0.0001 for both) and C-reactive protein level (133 vs. 97mg/L, P = 0.008, Table 2). E. coli was more common in CFAC (72.4% vs. 54% of positive blood cultures, P = 0.004). In bile cultures, Enterococci and multi-drug-resistant Gram negatives tended to be more frequent in CAAC than in CFAC (63 vs. 17%, P = 0.07 and 9.1% vs. 4.1%, P = 0.33, Table 2), respectively. CAAC more frequently required drainage (86.1% of cases vs. 43.6% in CFAC (P < 0.0001), including radiological drainage (42.5% vs. 12.5%; P = 0.008) and with multiple sessions (28.7% vs. 8.3%, P < 0.0001, Table 3). Antibiotherapy duration did not differ between the two groups. Despite similar initial severity, only 51.5% of patients with CAAC were alive, without febrile recurrence or other biliary drainage at day 28, vs. 85.5% of patients with CFAC (P < 0.0001, Table 3). Conclusion Despite comparable initial clinical presentation, management is more complex and outcome less favorable in CAAC vs. CFAC. Disclosures All authors: No reported disclosures.

BACKGROUND Solid pseudopapillary tumors (SPPTs) are low malignant potential entities found mainly in young females.1,2 Pancreatectomy without tumor rupture is the treatment of choice, and the laparoscopic approach is indicated.3,4 Limited pancreatectomy is possible due to the low risk of malignancy (

Pancreatic ductal adenocarcinoma (PDAC) is expected to become the second cause of cancer-related death in 2030. PDAC is the poorest prognostic tumor of the digestive tract, with 80% of patients having advanced disease at diagnosis and 5-year survival rate not exceeding 7%. Until 2010, gemcitabine was the only validated therapy for advanced PDAC with a modest improvement in median overall survival as compared to best supportive care (5-6 vs 3 months). Multiple phase II-III studies have used various combinations of gemcitabine with other cytotoxics or targeted agents, most in vain, in attempt to improve this outcome. Over the past few years, the landscape of PDAC management has undergone major and rapid changes with the approval of the FOLFIRINOX and gemcitabine plus nab-paclitaxel regimens in patients with metastatic disease. These two active combination chemotherapy options yield an improved median overall survival (11.1 vs 8.5 months, respectively) thus making longer survival a reasonably achievable goal. This breakthrough raises some new clinical questions about the management of PDAC. Moreover, better knowledge of the environmental and genetic events that underpin multistep carcinogenesis and of the microenvironment surrounding cancer cells in PDAC has open new perspectives and therapeutic opportunities. In this new dynamic context of deep transformation in basic research and clinical management aspects of the disease, we gathered updated preclinical and clinical data in a multifaceted review encompassing the lessons learned from the past, the yet unanswered questions, and the most promising research priorities to be addressed for the next 5 years.

International audience; OBJECTIVES: The aim of this study is to compare at a national level, the early and long-term outcome of distal pancreatectomy (DP) performed by laparoscopy (LapDP) or open surgery (OpenDP) for pancreatic ductal adenocarcinoma (PDAC). BACKGROUND DATA: LapDP is feasible and safe for benign conditions but its use for PDAC is controversial. METHODS: French healthcare databases were screened to identify all patients who had undergone LapDP or OpenDP for PDAC between 2007 and 2012. Endpoints were (i) 90-day mortality, (ii) morbidity, (iii) transfusion rate, (iv) length of hospital stay (LOS), and (v) long-term survival. Logistic regression and adjusted Cox models were used to compare LapDP and OpenDP with regard to these outcomes. Confounders included (i) patients' characteristics; (ii) associated surgical procedures; and (iii) characteristics of the hospital. Performance of the resulting models was determined by the area under the receiver operating characteristic (ROC) curve. RESULTS: Over the 6-year period, there were 2753 operations for PDAC: 2406 OpenDP and 347 LapDP (12.6%). The overall 90-day mortality rate was 5.2%; median LOS was 15 days, and median survival was 38 months. LapDP was not correlated with 90-day mortality but was associated with reduced pleuropulmonary morbidity (odds ratio (OR) 0.73, P = 0.028), blood transfusion (OR 0.44, P = 0.001), and LOS (P = 0.042), and was associated with increased survival (P = 0.0007). CONCLUSIONS: LapDP has not been adopted widely for PDAC. The early and long-term results of LapDP as currently practiced are as good as those of OpenDP. The next step in the evaluation of LapDP should be a randomized controlled trial (RCT), but such a trial is likely to suffer from insufficient recruitment

Purpose: The roles of intravisceral and subcutaneous fat are unknown, and the prevalence of precancerous lesions in obese patients was never evaluated. This study aims to assess the frequency and severity of pancreatic intraepithelial neoplasia (PanIN) and to correlate pathologic findings with metabolic abnormalities, type of fat, and fatty pancreatic infiltration. Experimental Design: Normal pancreatic tissue from surgical specimens was analyzed. Fatty infiltration and fibrosis in intra- and extralobular locations and PanIN lesions were assessed. General characteristics were collected: body mass index (BMI), diabetes, and tobacco intake. Liver steatosis and subcutaneous and intravisceral fat were assessed by CT scan (ImageJ software). Results: Of note, 110 patients were included [median age, 53.8 (17–85) years]. Arterial hypertension, diabetes, and tobacco intake were found in 19%, 9%, and 23%, respectively. Median BMI was 24 (16–37; BMI < 25: 45%, 25 ≤ 30: 24%, ≥30: 11%). Overall, PanIN lesions were found in 65% (type I, II, and III PanIN in 62%, 38%, and 1%, respectively). Fibrosis and fatty pancreas (intra- and extralobular locations) were found in 1% and 24% and in 30% and 51%, respectively. A correlation was observed between PanIN lesions and fatty pancreas [extralobular (0.01) and intralobular ( Conclusions: Obesity (especially android obesity) and pancreatic fatty infiltration are risk factors for pancreatic precancerous lesions. Clin Cancer Res; 21(15); 3522–8. ©2015 AACR. See related commentary by Wang et al., p. 3369

Objective To evaluate the parietal peritoneum (PP) as an autologous substitute for venous reconstruction during hepatopancreatobiliary (HPB) surgery. Background Venous resection during liver or pancreatic resection may require a rapidly available substitute especially when the need for venous resection is unforeseen. Methods The PP was used as an autologous substitute during complex liver and pancreatic resections. Postoperative anticoagulation was standard and venous patency was assessed by routine computed tomographic scans. Results Thirty patients underwent vascular resection during pancreatic (n = 18) or liver (n = 12) resection, mainly for malignant tumors (n = 29). Venous resection was an emergency procedure in 4 patients due to prolonged vascular occlusion. The PP, with a mean length of 22 mm (15-70), was quickly harvested and used as a lateral (n = 28) or a tubular (n = 2) substitute for reconstruction of the mesentericoportal vein (n = 24), vena cava (n = 3), or hepatic vein (n = 3). Severe morbidity included Clavien grade-III complications in 4 (13%) patients but there was no PP-related or hemorrhagic complications. Histological vascular invasion was present in 18 (62%) patients, and all had an R0 resection (100%). After a mean follow-up of 14 (7-33) months, all venous reconstructions were patent except for 1 tubular graft (97%). Conclusions A PP can be safely used as a lateral patch for venous reconstruction during HPB surgery; this could help reduce reluctance to perform vascular resection when oncologically required. Clinical trials identification: NCT02121886.

Parenchyma-sparing pancreatectomy, including enucleation and central pancreatectomy, has been investigated as an alternative to standard resection (pancreaticoduodenectomy or left/distal pancreatectomy) for pancreatic neuroendocrine tumor (PNET). In selected patients, with small (

Serous cystadenoma (SC) is a benign pancreatic cystic tumor. Surgical resection is recommended for symptomatic forms, but laparoscopic fenestration of large symptomatic macrocystic SC was not yet described in the literature. In this study, 3 female patients underwent laparoscopic fenestration for macrocystic SC (12-14 cm). Diagnosis was established via magnetic resonance imaging and endoscopic ultrasound, with intra-cystic dosage of tumors markers (ACE and CA19-9) in 2 patients. All patients were symptomatic and operated on 15-60 mo after diagnosis. Radiological evaluation showed constant cyst growth. Patients were informed about this new surgical modality that can avoid pancreatic resection. The mean operative time was 103 min (70-150 min) with one conversion. The post-operative course was marked by a grade A pancreatic fistula in one patient and was uneventful in the other two. The hospital stay was 3, 10, and 18 d, respectively. The diagnosis of macrocystic SC was histologically-confirmed in all cases. At the last follow-up (13-26 mo), all patients were symptom-free, and radiological evaluation showed complete disappearance of the cyst. Laparoscopic fenestration, as opposed to resection, should be considered for large symptomatic macrocystic SC, thereby avoiding pancreatic resection morbidity and mortality.

Laparoscopic pancreaticoduodenectomy (LPD) is a difficult procedure that has become increasingly popular. Nevertheless, comparative data on outcomes remain limited. Our aim was to compare the outcomes of LPD and open pancreaticoduodenectomy (OPD).Between April 2011 and April 2014, 46 LPD were performed and compared with 46 OPD, which theoretically can be done by the laparoscopic approach. Patients were also matched for demographic data, associated comorbidities, and underlying disease. Patient demographics and perioperative and postoperative outcomes were studied from our single center prospective database.Lower BMI (23 vs 27 kg/m(2), p0.001) and a soft pancreas (57% vs 47%, p = 0.38) were observed in patients with LPD, but there were no differences in associated comorbidities or underlying disease. Surgery lasted longer in the LPD group (342 vs 264 minutes, p0.001). One death occurred in the LPD group (2.1% vs 0%, p = 0.28) and severe morbidity was higher (28% vs 20%, p = 0.32) in LPD due to grade C pancreatic fistula (PF) (24% vs 6%, p = 0.007), bleeding (24% vs 7%, p = 0.02), and revision surgery (24% vs 11%, p = 0.09). Pathologic examination for malignant diseases did not identify any differences between the LPD and OPD as far as size (2.51 vs 2.82 cm, p = 0.27), number of harvested (20 vs 23, p = 0.62) or invaded (2.4 vs 2, p = 0.22) lymph nodes, or R0 resection (80% vs 80%; p = 1). Hospital stays were similar (25 vs 23 days, p = 0.59). There was no difference in outcomes between approaches in patients at a lower risk of PF.This study found that LPD is associated with higher morbidity, mainly due to more severe PF. Laparoscopic pancreaticoduodenectomy should be considered only in the subgroup of patients with a low risk of PF.

Ampullary carcinoma (AC) is a relatively rare entity often managed as a biliopancreatic carcinoma. AC has a better prognosis than peri ampullary tumors after resection, but more than a third of patients relapse. Factors predictive of recurrence are controversial, mainly because the relevant studies are very small or also included non AC tumors. There are no guidelines on the use of adjuvant or neoadjuvant chemotherapy. The aim of this study was to identify prognostic factors for recurrence after AC resection in a large multicentric cohort, and to establish a simple, practical, predictive score for recurrence in order to guide multidisciplinary decisions.We included 152 consecutive patients who underwent Whipple's pancreaticoduodenectomy for ampullary carcinoma from January 2000 to December 2010 in 10 gastrointestinal oncology departments.The estimated overall 5-year disease-free survival rate (DFS) was 47.1%. In multivariate analysis, age≥ 75 years at diagnosis (p0.0001), poor general condition (p = 0.01), poorly (p = 0.005) or moderately differentiated tumors (p = 0.01) and TNM stage IIb or III (p = 0.05) were associated with poor DFS. Based on this multivariate analysis, we developed a prognostic score with three levels of risk: DFS at 5 years was 73.5% in the low-risk group and 20.1% in the high-risk group.This simple score based on age, general condition, tumor differentiation and TNM stage can classify patients into subgroups with different risks of recurrence and could help with therapeutic decisionmaking.

Although laparoscopic surgery is now extensively used, laparoscopic middle pancreatectomy (LMP) has rarely been described.A 45-year-old woman was diagnosed with branch duct intraductal papillary mucinous neoplasia (IPMN) at the pancreatic neck, which was discovered after numerous attacks of acute pancreatitis. LMP was decided on for treatment.The patient underwent pure LMP with right to left dissection and one-layer pancreatogastric anastomosis. Surgery lasted 160 minutes, with 20 mL of blood loss. A frozen section showed negative margins on both sides. The postoperative course was uneventful with 15 days in the hospital. Histology confirmed the diagnosis of branch duct IPMN with moderate dysplasia and negative margins. The patient is symptom free 6 months after surgery.Our results and the data in the literature suggest that the laparoscopic approach is indicated for middle pancreatectomy because there are no technical or oncological contraindications and the outcome is similar to that with the open approach.

Venous resection (VR) during pancreatectomy has been reported to neither increase mortality nor morbidity and to provide similar survival outcomes in same stage tumors. However, controversy remains regarding the indications for up-front surgery according to the degree of venous involvement. From 2004 to 2009, 1,399 patients included in a French multicenter survey underwent pancreaticoduodenectomy or total pancreatectomy for pancreatic adenocarcinoma, either without VR (997 standard resections [SR]) or with VR (402 patients; 29 %). Postoperative and long-term outcomes were compared in both groups. VR was associated with the following factors: larger tumors (p

Background On the basis of now dated studies, cirrhosis is usually considered to be a contraindication in pancreatoduodenectomy (PD) for adenocarcinoma of the pancreatic head (APH). Objective Examine the outcomes of PD for APH in the presence of cirrhosis. Methods Retrospective, multicenter study of cirrhotic patients with APH having undergone PD between January 2004 and March 2012. Cirrhotic patients were matched 1:2 for demographic, surgical and histologic criteria with non-cirrhotic patients. Primary endpoint was morbidity and mortality. Secondary endpoints were surgical parameters, morbidity related to pancreatic surgery and cirrhosis, and follow-up. Results We included 35 patients with cirrhosis. Twenty-four patients (69%) were Child A and none were Child C. The Child A cirrhotic patients and non-cirrhotic patients respectively had complication rates of 79% vs. 43% (P = 0.002), major complication rates of 33% vs. 21% (P = 0.26), pancreatic fistula rates of 13% vs. 9% (P = 0.57), post-operative mortality of 4% vs. 5% (P = 0.94), 3-year overall survival rates of 44% vs. 50% (P = 0.46). All Child B cirrhotic patients experienced post-operative complications. Conclusion Pancreatoduodenectomy for APH was possible in Child A cirrhotic patients with a mortality and long-term outcomes equivalent to non-cirrhotic patients. Child B cirrhosis remains a clear contraindication to surgery. J. Surg. Oncol. 2015 111:776–783. © 2015 Wiley Periodicals, Inc. J. Surg. Oncol. 2015 111:776–783. © 2015 Wiley Periodicals, Inc.

Resume La fistule anastomotique est une complication majeure en chirurgie digestive, responsable d’une augmentation de la morbidite postoperatoire, et premiere cause de mortalite apres chirurgie d’exerese. L’identification des facteurs de risque est un prerequis indispensable a la prevention de la fistule. La fistule peut se manifester par differents tableaux cliniques, allant de l’absence de symptomes, au choc septique avec mise en jeu du pronostic vital. Le scanner injecte avec opacification est l’examen le plus exhaustif pour l’exploration de tout type de fistule et de ses repercussions. Un diagnostic precoce et une prise en charge optimale multidisciplinaire de la fistule permettent de diminuer la morbi-mortalite postoperatoire. Elle est basee sur trois options : medicale, interventionnelle de type radiologique ou endoscopique, ou chirurgicale, dont le choix depend de l’etat septique du malade. Si le patient est asymptomatique, le traitement peut etre exclusivement medical avec une surveillance rapprochee. Un traitement interventionnel est entrepris pour une fistule symptomatique si le pronostic vital n’est pas engage. Si par contre le pronostic vital est mis en jeu, une reintervention chirurgicale en urgence est necessaire, associee a une reanimation intensive. Plus que leur prevention, c’est la precocite et la qualite de la prise en charge des fistules anastomotiques qui en diminuent leur retentissement.

Anastomotic leakage represents a major complication of gastrointestinal surgery, leading to increased postoperative morbidity; it the foremost cause of mortality after intestinal resection. Identification of risk factors is essential for the prevention of AL. AL can present with various clinical pictures, ranging from the absence of symptoms to life-threatening septic shock. Contrast-enhanced CT scan is the most complete investigation to define AL and its consequences. Early and optimal multidisciplinary management is based on three options: medical management, radiologic or endoscopic intervention, or surgical re-intervention. Prompt treatment should help decrease postoperative morbidity and mortality, with the choice depending on the septic status of the patient. If the patient is asymptomatic, treatment can be medical only, coupled with close surveillance. Interventional management is indicated when the fistula is symptomatic but not life-threatening. On the other hand, when the vital prognosis is engaged, surgery is indicated, emergently, associated with intensive care. Even more than their prevention, early and appropriate management counts most to decrease their consequences.

Background Gastric stump carcinoma is an exceptional and poorly known long-term complication after pancreaticoduodenectomy. Cases presentation Two patients developed gastric stump carcinoma 19 and 10 years after pancreaticoduodenectomy for malignant ampulloma and total pancreaticoduodenectomy for pancreatic adenocarcinoma, respectively. Both patients had pT4 signet-ring cell carcinoma involving the gastrojejunostomy site that was revealed by bleeding or obstruction. Patient 1 is alive and remains disease-free 36 months after completion gastrectomy. Patient 2 presented with peritoneal carcinomatosis and died after palliative surgery. We identified only 3 others cases in the English literature. Conclusions Prolonged biliary reflux might be the most important risk factor of gastric stump carcinoma following pancreaticoduodenectomy. Its incidence might increase in the future due to prolonged survival observed after pancreaticoduodenectomy for benign and premalignant lesions.

International audience; Microsatellite instability (MSI) caused by mismatch repair deficiency (dMMR) is detected in a small proportion of pancreatic ductal adenocarcinomas (PDACs). dMMR and MSI have been associated with responses of metastatic tumors, including PDACs, to immune checkpoint inhibitor therapy. We performed immunohistochemical analyses of a 445 PDAC specimens, collected from consecutive patients at multiple centers, to identify those with dMMR, based on loss of mismatch repair proteins MLH1, MSH2, MSH6, and/or PMS2. We detected dMMR in 1.6% of tumor samples; we found dMMR in a larger proportion of intraductal papillary mucinous neoplasms-related tumors (4/58, 6.9%) than non- intraductal papillary mucinous neoplasms PDAC (5/385, 1.3%) (P = .02). PDACs with dMMR contained potentially immunogenic mutations because of MSI in coding repeat sequences. PDACs with dMMR or MSI had a higher density of CD8+ T cells at the invasive front than PDACs without dMMR or MSI (P = .08; Fisher exact test). A higher proportion of PDACs with dMMR or MSI expressed the CD274 molecule (PD-L1, 8/9) than PDACs without dMMR or MSI (4/10) (P = .05). Times of disease-free survival and overall survival did not differ significantly between patients with PDACs with dMMR or MSI vs without dMMR or MSI. Studies are needed to determine whether these features of PDACs with dMMR or MSI might serve as prognostic factors.

The aim of the study was to assess the relevance of resection margin status for survival after resection of pancreatic-head ductal adenocarcinoma.The definition and prognostic value of incomplete microscopic resection (R1) remain controversial.Prognostic factors were analyzed in 147 patients included in a prospective multicenter study on the impact of tumor clearance evaluated using a standardized pathology protocol.Thirty patients received neoadjuvant treatment (NAT = 20%); 41 had venous resection (VR = 28%), and 70% received adjuvant chemotherapy. In-hospital mortality was 3% (5/147). Follow-up was 83 months. Tumor clearance was 0,1.0,1.5, and2.0 mm in 35 (25%), 92 (65%), 95 (67%), and 109 (77%) patients, respectively. R0-resection rates decreased from 75% to 35% when changing the definition of R1 status from R1-direct invasion (0 mm) to R11.0 mm. On univariate analysis, clearance1.0 or1.5 mm, pT stage, pN stage, LNR ≥0.2, tumor grade 3, and lymphovascular invasion were significantly associated with 5-year survival. On multivariate analysis, pN was the most powerful independent predictor (P = 0.004). Clearance1.0 or1.5 mm had borderline significance for the entire cohort, but was relevant in certain subgroups (upfront pancreatectomy (n = 117; P = 0.049); without VR or NAT (n = 87; P = 0.003); N+ without VR or NAT (n = 50; P = 0.004). No N0-patient had R1-0 mm. Additional independent risk predictors were (1) R11.0 mm for the SMA-margin in specific subgroups (upfront pancreatectomy, N0 patients without NAT, N+ patients without NAT or VR; (2) R1-0 mm posterior-margin for the NAT group (P = 0.004).Tumor clearance1.0 or1.5 mm was an independent determinants of postresection survival in certain subgroups. To avoid misinterpretation, future trials should specify the clearance margin in millimeter.ClinicalTrials.gov: NCT00918853.

Objective Measure the caseload of pancreatectomies that influences their short-term outcome, at a national level, and assess the applicability of a centralization policy. Background There is agreement that pancreatectomies should be centralized. However, previous studies have failed to accurately define a "high-volume" center. Methods French healthcare databases were screened to identify all adult patients who had elective pancreatectomies between 2007 and 2012. The patients' age, comorbidities, indication, and extent of surgery, and also the hospital administrative-type and location were retrieved. The annual-caseload of pancreatectomy was calculated for each hospital facility. The primary endpoint was 90-day mortality. Spline modeling was used to identify the different annual-caseload that influenced mortality. Logistic regressions were performed to assess if their influence was independent of confounders, and the accuracy of the model calculated. Results Overall, 22,366 patients underwent a pancreatectomy and the mortality was 8.1%. Two cut-offs were identified (25 and 65 per year): compared with centers performing >65 resections per year, the adjusted OR of mortality was 1.865 (1.529-2.276) in centers performing ≤25 resections per year and 1.234 (1.031-1.478) in those performing 26 to 65 resections per year. The average number of facilities performing ≤25, 26 to 65, and >65 pancreatectomies per year was 456, 20, and 9, respectively. The percentage of patients operated in these facilities was 56.6%, 19.9%, and 23.3%, respectively.For pancreaticoduodenectomies (12,670 patients; mortality 9.2%), there were 2 cut-offs (16 and 40 pancreaticoduodenectomies per year), and both were independent predictors of mortality (adjusted OR of 1.979 and 1.333). For distal pancreatectomies (7085 patients; 6.2% mortality), there were 2 cut-offs (13 and 25 distal pancreatectomies per year), but neither was an independent predictor of outcome (area under the receiver-operating characteristic curve of the model = 0.778). Conclusions Centralization of pancreatic surgery is theoretically justified, but currently unrealizable. As the incidence of pancreatic cancer increases, there is an urgent need to improve the training of surgeons and develop both intermediate and high-volume centers.

Pancreatic incidentalomas (PI) are nowadays common but the benefit-risk balance of surgery remains difficult to determine.Monocentric retrospective study of 881 pancreatectomies comparing resected PI with symptomatic lesion. Univariate and multivariate (MV) analyses were done to identify risk factors of malignancy in PI undergoing surgery.Overall, 32% of pancreatectomies were performed for PI. Median size of PI was 30 mm (vs 28 mm; p = 0.15) and 49% were cystic (vs 42%; p = 0.197). Resected PI were mostly located in distal pancreas (61% vs 34%; p 0.001), less frequently malignant (49% vs 59%; p = 0.004). PNETs were more frequent in PI (50% vs 21%; p 0.001). Distal pancreatectomy (36% vs 23%; p 0.001) or parenchyma-sparing surgery (34% vs 13%; p 0.001) were more frequently performed for PI. Overall mortality (1.1% vs 1.2%) and morbidity (70% vs 68%) were not significantly different between both groups. Severe morbidity was lower for PI (15% vs 22%; p = 0.007). In multivariate analysis, age55 years (HR 6.14; p 0.001), size20 mm (HR:26.7; p 0.001) and biliary dilatation (HR 29.9; p = 0.027) were independent risk factors of malignancy and, when associated, the likelihood of malignancy was above 90%.PI represent about 30% of indications for pancreatectomy and when resected after careful selection are malignant in 50% of cases.

Lateral injury of the bile duct can occur after cholecystectomy, bile duct dissection, or exploration. If direct repair is not possible, conversion to bilioenteric anastomosis can be needed with the risk of long-term bile duct infections and associated complications. We developed a new surgical technique which consist of reconstructing the bile duct with the round ligament. The vascularized round ligament is completely mobilized until its origin and used for lateral reconstruction of the bile duct to cover the defect. T tube was inserted and removed after few months. Patency of the bile duct was assessed by cholangiography, the liver function test and magnetic resonance imaging (MRI). Two patients aged 33 and 59 years old underwent lateral reconstruction of the bile duct for defects secondary to choledocotomy for stone extraction or during dissection for Mirizzi syndrome. The defects measured 2 and 3 cm and occupied half of the bile duct circumference. The postoperative course was marked by low output biliary fistula resolved spontaneously. In one patient, the T tube was removed at 3 months after surgery and MRI at 9 months showed strictly normal aspect of the bile duct with normal liver function test. The second patient is going very well 2 months after surgery and the T tube is closed. Lateral reconstruction of the bile duct can be safely achieved with the vascularized round ligament. We will extend our indications to tubular reconstruction.