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Objectives: To assess the impact of neoadjuvant chemoradiotherapy (NCRT) on anastomotic leakage (AL) and other postoperative outcomes after esophageal cancer (EC) resection., Background: Conflicting data have emerged from randomized studies regarding the impact of NCRT on AL., Methods: Among 2944 consecutive patients operated on for EC between 2000 and 2010 in 30 European centers, patients treated by NCRT after surgery (n=593) were compared with those treated by primary surgery (n=1487). Multivariable analyses and propensity score matching were used to compensate for the differences in some baseline characteristics., Results: Patients in the NCRT group were younger, with a higher prevalence of male sex, malnutrition, advanced tumor stage, squamous cell carcinoma, and surgery after 2005 when compared with the primary surgery group. Postoperative AL rates were 8.8% versus 10.6% (P=0.220), and 90-day postoperative mortality and morbidity rates were 9.3% versus 7.2% (P=0.110) and 33.4% versus 32.1% (P=0.564), respectively. Pulmonary complication rates did not differ between groups (24.6% vs 22.5%; P=0.291), whereas chylothorax (2.5% vs 1.2%; P=0.020), cardiovascular complications (8.6% vs 0.1%; P=0.037), and thromboembolic events (8.6% vs 6.0%; P=0.037) were higher in the NCRT group. After propensity score matching, AL rates were 8.8% versus 11.3% (P=0.228), with more chylothorax (2.5% vs 0.7%; P=0.030) and trend toward more cardiovascular and thromboembolic events in the NCRT group (P=0.069). Predictors of AL were high American Society of Anesthesiologists scores, supracarinal tumoral location, and cervical anastomosis, but not NCRT., Conclusions: Neoadjuvant chemoradiotherapy does not have an impact on the AL rate after EC resection (NCT 01927016).

Background: Sleeve gastrectomy is a bariatric surgical procedure that may result in particular morbidity or mortality due to gastric fistula in the proximal part of the gastric tube. Two theories are currently proposed to explain this specific leak location. The vascular theory attributes the leaks to reduced perfusion in the gastric tube, and the mechanical theory suggests the etiology as gastric tube hyper-pressure due to pyloric conservation. The aim of this study was to map the arterial gastric vascular supply on fresh cadavers after performing sleeve gastrectomy to evaluate the effect of vascular changes on gastric leakage., Methods: We performed sleeve gastrectomies on 11 cadaveric trunks with a detailed anatomical study of the gastric vascular supply after latex injection in the three branches arising from the celiac trunk., Results: In 55 % of cases, the sleeve procedure changed the gastric vascular supply. In 9.1 %, it divided the three left gastric artery branches arising from the lesser curvature. Few changes were noted in the antrum or pylorus., Conclusions: This anatomical study demonstrates that the vascular supply of the proximal part of the gastric tube can be damaged by a sleeve procedure, which can sever one or more of the branches arising from the left gastric artery. Such weakness could be exacerbated by disparities in vascular supply. The uninterrupted vascular supply of the antrum and pylorus may explain the preferential localization of the fistula to the proximal part of the gastric tube.

Background: Recommendations for secondary hyperparathyroidism (SHPT) consider that a "one-size-fits-all" target enables efficacy of care. In routine clinical practice, SHPT continues to pose diagnosis and treatment challenges. One hypothesis that could explain these difficulties is that dialysis population with SHPT is not homogeneous., Methods: EPHEYL is a prospective, multicenter, pharmacoepidemiological study including chronic dialysis patients (≥ 3 months) with newly SHPT diagnosis, i.e. parathyroid hormone (PTH) ≥ 500 ng/L for the first time, or initiation of cinacalcet, or parathyroidectomy. Multiple correspondence analysis and ascendant hierarchical clustering on clinico-biological (symptoms, PTH, plasma phosphorus and alkaline phosphatase) and treatment of SHPT (cinacalcet, vitamin D, calcium, or calcium-free calcic phosphate binder) were performed to identify distinct phenotypes., Results: 305 patients (261 with incident PTH ≥ 500 ng/L; 44 with cinacalcet initiation) were included. Their mean age was 67 ± 15 years, and 60% were men, 92% on hemodialysis and 8% on peritoneal dialysis. Four subgroups of SHPT patients were identified: 1/ "intermediate" phenotype with hyperphosphatemia without hypocalcemia (n = 113); 2/ younger patients with severe comorbidities, hyperphosphatemia and hypocalcemia, despite SHPT multiple medical treatments, suggesting poor adherence (n = 73); 3/ elderly patients with few cardiovascular comorbidities, controlled phospho-calcium balance, higher PTH, and few treatments (n = 75); 4/ patients who initiated cinacalcet (n = 43). The quality criterion of the model had a cut-off of 14 (>2), suggesting a relevant classification., Conclusion: In real life, dialysis patients with newly diagnosed SHPT constitute a very heterogeneous population. A "one-size-fits-all" target approach is probably not appropriate. Therapeutic management needs to be adjusted to the 4 different phenotypes.

Background: Some patients operated by pancreaticoduodenectomy for resectable pancreatic head adenocarcinoma will present with a recurrence during the first year (early recurrence)., Objective: The aim of this study was to determine prognostic factors associated with early recurrence in a large retrospective study., Methods: From January 1995 to November 2010, all patients operated by pancreaticoduodenectomy for pancreatic head adenocarcinoma in our institution were retrospectively included. Univariate and multivariate analyses were performed to determine factors associated with early recurrence., Results: A total of 166 patients were included; 57 patients (34%) developed early recurrence. In univariate analysis, factors associated with early recurrence were perineural invasion (p = 0.0002), preoperative bilirubin (p = 0.01), lymph node ratio (LNR) ≥0.2 (p = 0.009), and T stage (p = 0.02). In multivariate analysis, perineural invasion (odds ratio [OR] 3.31; 95% confidence interval [CI] 1.42-7.72; p = 0.005), LNR ≥0.2 (OR 2.55; 95% CI 1.17-5.52; p = 0.02), and preoperative bilirubin (OR 1.04; 95% CI 1.01-1.07; p = 0.03) were independent factors associated with early recurrence. Perineural invasion was also associated with poor overall survival (p = 0.001) and poor disease-free survival (p = 0.07)., Conclusion: In our study, perineural invasion (OR 3.31) is more accurate than T stage and lymph node status (OR 2.55) to predict early recurrence after pancreatoduodenectomy for pancreatic head adenocarcinoma.

Robotic surgery offers potential technical advantages that may facilitate pancreatic resection. The aim of this study was to evaluate the learning curve and short-term perioperative outcomes in patients who underwent laparoscopic and robot-assisted distal pancreatectomy. All perioperative variables were evaluated and compared retrospectively between laparoscopic (LDP) (n = 23) and robot-assisted (RDP) (n = 11) distal pancreatectomy. The mean total operative time was shorter in LDP (194 vs. 225 min; p = 0.017). All other perioperative criteria were similar between LDP and RDP patients (blood loss, transfusion rate, conversion, pancreatic fistula, postoperative morbidity, and duration of hospitalization). Non-adjusted CUSUM curve for composite events including operative time, conversion, postoperative morbidity and reoperation rates showed that the RDP learning curve corresponded to the first seven consecutive patients. During early experience, RDP was associated with longer operative time but similar short-term perioperative outcomes compared to conventional distal pancreatectomy.

Background: Synchronous endoscopic bilateral adrenalectomy (BilA) can effectively provide definitive cure of hypercortisolism in ACTH-dependent Cushing's syndrome and in primary adrenal bilateral disease. We compared three different approaches for BilA: transabdominal laparoscopic BilA (TL-BilA), simultaneous posterior retroperitoneoscopic BilA (PR-BilA), and robot-assisted BilA (RA-BilA)., Methods: All patients who underwent BilA between January 1999 and December 2012 at two referral centers (one performing TL-BilA and PR-BilA and one performing RA-BilA) were included. A comparative analysis was performed., Results: Twenty-nine patients were included: 5 underwent TL-BilA, 11 underwent PR-BilA, and 13 underwent RA-BilA. No significant difference was found concerning age, gender, diagnosis, and previous abdominal surgery. No conversion to open approach was registered. Operative time was significantly shorter for the PR-BilA group than for the TL-BilA and RA-BilA groups (157.4 ± 54.6 vs 256.0 ± 43.4 vs 221.5 ± 42.2 min, respectively) (P < 0.001). No significant difference was found concerning intraoperative and postoperative complications rate and time to first flatus. Drains were used routinely after PR-BilA and TL-BilA and electively in four RA-BilA patients (P < 0.001). Hospital stay was longer in the TL-BilA and PR-BilA groups than in the RA-BilA group (12.0 ± 5.7 vs 10.8 ± 3.7 vs 4.4 ± 1.7 days, respectively) (P < 0.001). No recurrence or disease-related death was registered., Conclusions: Operative time was significantly shorter in the PR-BilA group, because it eliminates the need to reposition the patient. The number of drains and the length of hospital stay were reduced after RA-BilA, but this was likely related to different management protocols in different settings. Because no significant difference was found in terms of postoperative outcome, none of the three operative approaches can be considered the preferable one.

Aim: Full-thickness rectal prolapse is common in the elderly, but there are no particular practice guidelines for its surgical management. We evaluated retrospectively the perioperative and long-term clinical results and function in elderly and younger patients with complete rectal prolapse after robotic-assisted laparoscopic rectopexy (RALR)., Method: Seventy-seven patients who underwent RALR between 2002 and 2010 were divided into Group A (age < 75 years, n = 59) and Group B (age > 75 years, n = 18). Operative time, intra- and postoperative complications, length of hospital stay, short-term and long-term outcomes, recurrence rate and degree of satisfaction were evaluated., Results: There was no significant difference between the groups regarding operation time, conversion, morbidity or length of hospital stay. At a median follow-up of 51.8 (5-115) months, there was no difference in the improvement of faecal incontinence, recurrence and the degree of satisfaction., Conclusion: Robotic-assisted laparoscopic rectopexy is safe in patients aged over 75 years and gives similar results to those in patients aged < 75 years., (Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland.)

Introduction: The most cost-effective diagnostic algorithm for gastroesophageal reflux disease (GERD) remains controversial. We hypothesized that prompt referral for esophageal pH monitoring is more cost-effective than prolonged empiric courses of proton-pump inhibitors (PPIs)., Discussion: A cost model was created based on a cohort of 100 patients with possible GERD who underwent pH monitoring. The additional costs incurred from pH monitoring were compared to the potential savings from avoiding unnecessary PPI usage in patients with a negative pH study. The costs of PPI therapy reach equivalence with pH monitoring after 6.4 to 23.7 weeks, depending on the PPI regimen. A total of 21,411 weeks of PPIs were prescribed beyond the recommended 8-week trial, of which 32 % were for patients who had a negative 24-h pH monitoring study. If the sensitivity of pH monitoring was 96 %, early referral for pH monitoring would have saved between $1,197 and $6,303 per patient over 10 years. This strategy remains cost-effective as long as the sensitivity of pH monitoring is above 35 %. Prompt referral for pH monitoring after a brief empiric PPI trial is a more cost-effective strategy than prolonged empiric PPI trials for patients with both esophageal and extraesophageal GERD symptoms.

Paragangliomas (PGLs) are frequently associated with germline mutations in genes involved in energy metabolism. The purpose of the present study was to assess whether the tumor metabolomic profile of patients with hereditary and apparently sporadic PGLs enables the distinction of different subtypes of tumors. Twenty-eight unrelated patients with a histological diagnosis of PGLs were included in the present study. Twelve had germline mutations in SDHx genes (5 SDHB, 7 SDHD), 6 VHL, and 10 were apparently sporadic. Intact tumor samples from these patients (one per patient) were evaluated with (1)H high-resolution magic angle spinning (HRMAS) NMR spectroscopy. SDHx-related tumors were characterized by an increase in succinate levels in comparison to other tumor subtypes (p = 0.0001 vs VHL and p = 0.000003 vs apparently sporadic). Furthermore, we found significantly lower values of glutamate in SDHx-related tumors compared to other subtypes (p = 0.0007 vs VHL and p = 0.003 vs apparently sporadic). Moreover, SDHx-tumors also exhibited lower values of ATP/ADP/AMP (p = 0.01) compared to VHL. VHL tumors were found to have the highest values of glutathione (GSH) compared to other tumors. Based on 4 metabolites (succinate, glutamate, GSH, and ATP/ADP/AMP), tumors were accurately distinguished from the other ones on both 3- and 2-class PLS-DA models. The present study shows that HRMAS NMR spectroscopy is a very promising method for investigating the metabolomic profile of various PGLs. The present data suggest the existence of a specific succinate-glutamate hallmark of SDHx PGLs. The relevance of such a metabolomic hallmark is expected to be very useful in designing novel treatment options as well as improving the diagnosis and follow-up of these tumors, including metastatic ones.

Introduction: Malignant tumours of the adrenal gland are adrenocortical carcinomas (ACC), malignant phaeochromocytomas (MPC) or metastatic tumours. The objective of this article is to propose guidelines for the management of these tumours., Material and Methods: A review of the literature was performed by selecting articles on malignant tumours of the adrenal gland published in PUBMED., Results: Abdominal computed tomography is the reference first-line examination. A diameter > 6 cm, a heterogeneous appearance, irregular margins, spontaneous high density (> 20 HU) and delayed wash-out are radiological signs of malignancy. MRI can be used to characterize the tumour with a sensitivity of 89% and a specificity of 99%. Hormone assays and an endocrinology consultation are recommended before any management. When ACC is suspected, (18)FDG-PET is the reference scintigraphic examination, while the isotope of choice for MPC is (18)F-DOPA, which is more sensitive than MIBG. These scintigraphic examinations have a sensitivity close to 100% and allow staging of distant metastases. Percutaneous biopsy has a limited place in the diagnostic work-up. It is only indicated in the case of suspected adrenal metastasis after having excluded phaeochromocytoma and must not be performed in the case of suspected adrenocortical carcinoma. Surgery is first-line treatment for localized and resectable tumours, but is rarely curative due to the high recurrence rate. For ACC, adjuvant therapy by mitotane or adjuvant radiotherapy can be proposed. Metabolic radiotherapy with (131)I-MIBG can be proposed for the treatment of MPC. First-line chemotherapy is indicated in the case of advanced disease or unresectable tumour. Surgical treatment of adrenal metastasis by adrenalectomy is recommended depending on the type and prognosis of the primary cancer., Conclusion: Preoperative laboratory, morphological and scintigraphic assessment is essential before any management. First-line treatment is surgical when the tumour is resectable, but must be completed by adjuvant therapy to limit the risk of recurrence., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Background: Laparoscopic Roux-en-Y gastric bypass is one of the most commonly performed bariatric operation worldwide for the surgical management of obesity. Totally robotic Roux-en-Y gastric bypass (TR-RYGBP) has been considered to be a better approach by some groups especially early in a surgeon's experience. However, the learning curve associated with TR-RYGBP has been poorly evaluated yet. The aim of this study was to evaluate the learning curve of patients who underwent TR-RYGBP., Methods: This is a prospective study of 154 first consecutive patients undergoing TR-RYGBP to analyze the influence of surgeon experience, bedside first assistant, and patient factors on operative time and postoperative complications. To give a comprehensive view of success related to the learning process, a single hybrid variable was generated. Multivariate analysis predicted the risk factors for complications and operative time. A risk-adjusted cumulative sum analysis estimated the learning curve., Results: The learning curve for TR-RYGBP was 84 cases. Case rank and first assistant level were independent predictors of total operative time. Overall 30-day postoperative morbidity rate was 33.1 % and decreased over time. Surgeon experience (OR 2.6; CI 95 [1.290 to 5.479]; p = 0.0081) and first assistant level (OR 2.42; CI 95 [1.197 to 4.895]; p = 0.0139) remained independent predictors of composite event (operative time and complications)., Conclusions: This study identifed criteria that should be assessed in future studies about TR-RYGBP. Both surgeon experience and bedside first assistant level affected operative duration, but surgeon experience was the most significant factor in reducing complication rates.

Background: Perioperative short-term outcomes could be improved after totally robotic Roux-en-Y gastric bypass (TR-RYGBP) compared with conventional laparoscopic gastric bypass., Methods: This is a nonrandomized controlled prospective study (N = 200) to evaluate perioperative short-term outcomes. The primary endpoint was to investigate risk factors for 30-day surgical complications., Results: Mean total operative time was shorter in patients who underwent TR-RYGBP (130 vs 147 minutes; P < .0001). However, postoperative surgical complications rate (13% vs 1%; P = .001), and mean overall hospital stay (9.3 vs 6.7 days; P < .0001) were higher after TR-RYGBP. By multivariate analysis, robotic surgery (hazard ratio [HR] = 15.1; 95% confidence interval [CI], 2.8 to 280; P = .01), and conversion to laparotomy (HR = 18.8; 95% CI, 1.7 to 250.8; P = .014) were independent risk factors for 30-day surgical complications., Conclusions: Although robotic gastric bypass reduces mean operative time, TR-RYGBP is associated with an increased postoperative surgical complications rate and longer hospitalization., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Robot-assisted laparoscopic rectopexy for total rectal prolapse is safe and feasible. Small series proved clinical and functional short-term results comparable with conventional laparoscopy. No long-term results have been reported yet., Objective: The primary objective of the study was to evaluate long-term functional and anatomic results of robot-assisted laparoscopic rectopexy. The secondary objective was to evaluate the learning curve of this procedure., Design: Monocentric study data, both preoperative and perioperative, were collected prospectively, and follow-up data were assessed by a telephone questionnaire., Settings: The study was performed in an academic center by 3 different surgeons., Patients: We evaluated all of the consecutive patients who underwent a robot-assisted laparoscopic rectopexy between June 2002 and August 2010., Intervention: Rectopexy was performed with 2 anterolateral meshes or with 1 ventral mesh, and in 9 patients a sigmoidectomy was associated with rectopexy., Main Outcome Measures: The actuarial recurrence rate was evaluated using the Kaplan-Meier method., Results: During the study period, 77 patients underwent a robot-assisted laparoscopic rectopexy, and the mean age was 59.9 years (range, 23-90 y). Average operating time was 223 minutes (range, 100-390 min); the learning curve was completed after 18 patients were seen. Two patients died of causes unrelated to surgery at 5 and 24 months. There were 5 conversions (6%) to open procedure. Overall morbidity was low and concerned only 8 patients (10.4%). Mean follow-up time was 52.5 months (range, 12-115 mo). Recurrences have been observed in 9 patients (12.8%). Preoperatively, 24 (34%) of the patients had constipation. Postoperatively, constipation disappeared for 12 (50%) of 24 and constipation appeared for 11 (24%) of 46 patients. Fecal incontinence decreased after surgery from Wexner score 10.5 to 5.1 of 20., Limitations: There was a lack of standardization of the surgical procedure. The study was monocentric. Seven patients (9%) were lost to follow-up., Conclusions: Long-term results of robot-assisted laparoscopic rectopexy are satisfying. Further studies comparing robot-assisted and conventional laparoscopy, including cost-effectiveness, are needed.

Purpose: The aim of this study was to assess the safety and efficacy of adrenalectomy on patients with pheochromocytoma diagnosed at the time of an acute heart failure (AHF)., Methods: We reported cases of patients who presented an AHF secondary to a pheochromocytoma during a period of 10 years. The diagnosis of AHF was defined by a left ventricular ejection fraction of less than 30 % or the use of circulatory assistance. They had adrenalectomy as emergency surgery or later. Morbidity and mortality of surgery were studied., Results: Thirteen patients required an adrenalectomy for AHF secondary to pheochromocytoma. Four patients (31 %) had an adrenalectomy in emergency. Nine patients (69 %) had a delayed surgery with a median delay of 25 days (7-180). Eight patients had circulatory assistance (61 %). Five of them had a circulatory assistance and a delayed surgery (38 %), two of them had a circulatory assistance followed by emergency surgery (at 1.5 and 3 days) and one had emergency surgery immediately followed by circulatory assistance. Emergency surgery was performed by laparotomy in all cases and delayed surgery by laparoscopy for seven patients (54 %). Perioperative complications consisted in: one circulatory arrest, two bleedings requiring transfusion, one intestinal ischaemia, one haemoperitoneum with re-operation (day 8). One patient died on day 5. Post-operative course of patients with delayed surgery was uneventful., Conclusions: AHF revealing a pheochromocytoma is a rare and serious event. Patients with emergency surgery have more complications than those with delayed surgery.

Purpose: This study evaluated the feasibility, safety, effectiveness, and long-term results of pelvic organ prolapse surgery using the Da Vinci robotic system., Methods: During a 7-year period, 52 consecutive patients with pelvic organ prolapse underwent robotic-assisted abdominal sacrocolpopexy. Clinical data were retrospectively collected and analyzed., Results: All but two of the procedures were successfully completed robotically (96 %). Median operative time was 190 (range, 75-340) mins. There was no mortality and no specific morbidity due to the robotic approach. Mean hospital stay was 5 days. The median follow-up was 42 months. Five recurrent prolapses (9.6 %) were diagnosed., Conclusions: Our experience indicates that using the Da-Vinci robotic system is feasible, safe, and effective for the treatment of pelvic organ prolapse with good long-term results.

Background: This study presents a cost analysis of the standard cervical, gasless transaxillary endoscopic, and gasless transaxillary robotic thyroidectomy approaches based on medical costs in the United States., Methods: A retrospective review of 140 patients who underwent standard cervical, transaxillary endoscopic, or transaxillary robotic thyroidectomy at 2 tertiary centers was conducted. The cost model included operating room charges, anesthesia fee, consumables cost, equipment depreciation, and maintenance cost. Sensitivity analyses assessed individual cost variables., Results: The mean operative times for the standard cervical, transaxillary endoscopic, and transaxillary robotic approaches were 121 ± 18.9, 185 ± 26.0, and 166 ± 29.4 minutes, respectively. The total cost for the standard cervical, transaxillary endoscopic, and transaxillary robotic approaches were $9,028 ± $891, $12,505 ± $1,222, and $13,670 ± $1,384, respectively. Transaxillary approaches were significantly more expensive than the standard cervical technique (standard cervical/transaxillary endoscopic, P < .0001; standard cervical/transaxillary robotic, P < .0001; and transaxillary endoscopic/transaxillary robotic, P = .001). The transaxillary and standard cervical techniques became equivalent in cost when transaxillary endoscopic operative time decreased to 111 minutes and transaxillary robotic operative time decreased to 68 minutes. Increasing the case load did not resolve the cost difference., Conclusion: Transaxillary endoscopic and transaxillary robotic thyroidectomies are significantly more expensive than the standard cervical approach. Decreasing operative times reduces this cost difference. The greater expense may be prohibitive in countries with a flat reimbursement schedule., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Evaluation of: Karabulut K, Agcaoglu O, Aliyev S et al. Comparison of intraoperative time use and perioperative outcomes for robotic versus laparoscopic adrenalectomy. Surgery 151(4), 537-542 (2012) Currently, laparoscopic adrenalectomy is regarded as the preferred surgical approach for the management of most adrenal surgical disorders. Despite the benefits of laparoscopic adrenalectomy over open approaches, the procedure has shortcomings such as the absence of 3D perception, reduced dexterity and poor ergonomics for the surgeon. Recently, robotic technology has been introduced and could theoretically improve the laparoscopic adrenalectomy procedure and lead to improved perioperative and postoperative outcomes. A recent study by Karabulut et al. provides a comparison of intraoperative time analysis and perioperative outcomes for robotic adrenalectomy versus laparoscopic adrenalectomy. These data suggest that the use of a robotic system could improve perioperative outcomes when performing an adrenalectomy.

Introduction: Pancreatectomies increase the risk of postoperative pancreatic fistula (POPF) and pancreatic insufficiency. Pancreatic enucleation preserves pancreatic parenchyma, lowers the risk of pancreatic insufficiency, but may induce specific complications (tumor recurrence or pancreatic fistulization). The aim of this study was to determine the risk factors for POPF following a pancreatic enucleation., Methods: A retrospective analysis was designed based on data from patients who underwent pancreatic enucleation in five university hospitals (1998-2008). The presence of a pancreatic fistula was determined according to the criteria of the International Study Group of Pancreatic Fistula (Bassi et al. Surgery 138:8-13, 2005)., Results: Fifty-two patients (mean age 52 years) were included. Histological analysis revealed 35 endocrine tumors (68.6 %), 6 mucinous and 2 serous cyst adenomas, 2 metastases of renal cancer, and 8 benign tumors. Nineteen patients (36.5%) suffered postoperative complications including 14 POPF (27 %). Median postoperative hospital stay was 12.9 days; 9.1 days without POPF versus 29 days with POPF (p < 0.05). Size of the tumor, its location, histological differentiation, and use of somatostatin analogs were not predictors for POPF. We defined the cutoff for POPF at a distance of 2 mm from the main pancreatic duct based on 60% risk (≤2 mm) versus 19 % (>2 mm) of POPF (p < 0.01). With a mean follow-up of 30.8 months, one patient experienced recurrence of the tumor. No patients exhibited a new onset of diabetes or pancreatic insufficiency., Conclusion: Enucleation for resection of pancreatic tumors located at less than or equal to two 2 mm from the main pancreatic duct is a risk factor for POPF. Enucleation is a safe and effective treatment for benign or borderline pancreatic tumors.

Background: Ectopic hormone-secreting pheochromocytomas are rare; only case reports exist in the literature. This condition has been linked with increased malignancy, familial syndromes, and ACTH secretion. We wanted to test these hypotheses and shed light on the nature of ectopic hormone-secreting pheochromocytomas., Methods: This is a multicenter (francophone) observational study. Inclusion was based upon abnormal preoperative hormone tests in patients with pheochromocytoma that normalized after removal of the tumor. Where possible, immunohistochemistry was performed to confirm that ectopic secretion came from the tumor., Results: Sixteen cases were found: nine female and seven male patients. Median age was 50.5 (range 31-89) years. Most presented with hypertension, diabetes, or cushingoid features. Ten patients had specific symptoms from the ectopic hormone secretion. Two had a familial syndrome. Of eight patients with excess cortisol secretion, three died as a result of the tumor resection: two had pheochromocytomas >15 cm and their associated cortisol hypersecretion complicated their postoperative course. The other died from a torn subhepatic vein. The 13 survivors did not develop any evidence of malignancy during follow-up (median 50 months). Symptoms from the ectopic secretion resolved after removal of the tumor. Immunohistochemistry was performed and was positive in eight tumors: five ACTH, three calcitonins, and one VIP., Conclusions: Most pheochromocytomas with ectopic secretion are neither malignant nor familial. Most ectopic hormone-secreting pheochromocytoma cause hypercortisolemia. Patients with a pheochromocytoma should be worked up for ectopic hormones, because removal of the pheochromocytoma resolves those symptoms. Associated cortisol secretion needs careful attention.

Introduction: Malignant pheochromocytomas (PCCs) and paragangliomas (PGLs) are rare disorders arising from the adrenal gland, from the glomera along parasympathetic nerves or from paraganglia along the sympathetic trunk. According to the WHO classification, malignancy of PCCs and PGLs is defined by the presence of metastases at non-chromaffin sites distant from that of the primary tumor and not by local invasion. The overall prognosis of metastasized PCCs/PGLs is poor. Surgery offers currently the only change of cure. Preferably, the discrimination between malignant and benign PCCs/PGLs should be made preoperatively., Methods: This review summarizes our current knowledge on how benign and malignant tumors can be distinguished., Conclusion: Due to the rarity of malignant PCCs/PGLs and the obvious difficulties in distinguishing benign and malignant PCCs/PGLs, any patient with a PCC/PGL should be treated in a specialized center where a multidisciplinary setting with specialized teams consisting of radiologists, endocrinologist, oncologists, pathologists and surgeons is available. This would also facilitate future studies to address the existing diagnostic and/or therapeutic obstacles.

Laparoscopic adrenalectomy has become the preferred method for removal of almost all adrenal tumors. An important component in selecting patients for this operation is a thorough understanding of the clinical presentation (mainly hypertension) and diagnostic workup for the full variety of functioning and nonfunctioning adrenal tumors including genetic evaluation when necessary (MEN2, VonHippel-Landau [VHL], type 1 neurofibromatosis [NF1], succinate dehydrogenase mutations [SDH], and MEN1). The indications and contraindications for a laparoscopic approach are discussed with regard to each tumor type. Relevant literature about partial and bilateral adrenalectomy is also summarized. Main areas of controversy are discussed including the size threshold to avoid risk of adrenal capsular effraction and the appropriateness of laparoscopic resection for suspected and known malignancy. This article presents recent data to help the surgeon make well-informed decisions and to optimize the operative approach for a wide variety of adrenal pathologies (secreting vs. non-secreting, benign vs. malignant tumors)., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Currently laparoscopic adrenalectomy (LA) is regarded as the preferred surgical approach for the management of most adrenal surgical disorders. Despite the benefits of LA, the procedure has shortcomings that are shared by other laparoscopic techniques. Commonly noted problems include the absence of 3-dimensional perception, reduced dexterity, and poor ergonomics for the surgeon. Recently, robotic technology has been introduced into laparoscopic clinical practice. The requirement for precise surgery in adrenalectomy is important, and the introduction of robotically assisted LA offers new possibilities. This review summarizes current available data regarding robotic adrenalectomy, including its indications, advantages, limitations, and comparison with conventional laparoscopic adrenalectomy. See the videos, Supplemental Digital Content 1, http://links.lww.com/SLE/A33, Supplemental Digital Content 2, http://links.lww.com/SLE/A34 and Supplemental Digital Content 3, http://links.lww.com/SLE/A35.

While somatostatin receptors (sst), through somatostatin-radiolabeled analogs, are used, mainly in second line, in the diagnosis and treatment of pheochromocytomas (PCC) and paragangliomas (PGL), the clinical significance of dopamine receptor subtype 2 (D₂) in PCC/PGL is unknown. Indeed, radiolabeled dopamine (DA) analogs such as fluorine 18 ((18)F)-DA, used for positron emission tomography in PCC localization, are mainly correlated to the presence of noradrenaline transporter (NAT) and vesicular monoamine transporters (VMAT) but not to D₂. The aim of this study was to quantitate D₂ and sst expression in 52 PCC/PGL and to compare it with that of 35 gastroenteropancreatic neuroendocrine tumors (GEP-NETs). Quantitative RT-PCR of sst(1-3) and sst₅, D₂, NAT, VMAT1/2 was performed in all tumors, while immunohistochemistry analysis of sst₂ and D₂ was performed in seven tumors. D₂ mRNA was expressed in all PCC/PGL. Mean expression was significantly higher in PCC/PGL than in GEP-NETs (4.8 vs 0.5 copy/copy β-glucuronidase (Gus)). sst₂ and sst(1) were expressed in most PCC/PGL, with sst(2)-dominant expression (mean mRNA: 1.6 vs 0.4 copy/copy β-Gus). sst₂ expression level was similar to that of GEP-NETs, whereas sst₅ expression level was significantly lower (0.12 vs 0.78 copy/copy β-Gus). Our study evidenced strong D₂ mRNA expression in PCC and for the first time in PGL. PCC/PGL express sst₂ mRNA at levels similar to those of GEP-NETs. New drugs can target ssts and D₂ more efficiently than current somatostatin analogs. Moreover, transporters like NAT and VMAT1/2, could be co-targeted with sst, as a basis of new radionuclide compounds in the imaging and treatment of these tumors.

In head and neck surgery, minimally invasive approaches have been typically avoided due to concerns about visualization, possible damage to vital structures, and limited availability of effective instrumentation. The incorporation of robotic technology in surgery is now an accepted fact, and because of the complexities of certain laparoscopic procedures, the extended capabilities offered by robotic technology have gained wide acceptance. We report the case of a patient who underwent a robotic total thyroidectomy using a gasless right transaxillary approach. This technique provides a high quality image leading to improved visualization of vital structures during thyroidectomy with the added advantage of avoidance of a neck incision. Several issues regarding this technique remain to be clarified and evaluated in multicenter studies: patient selection, surgeon training and learning curve, postoperative morbidity due to recurrent nerve and parathyroid injury, long term oncologic and cosmetic results. However, we believe that robotic thyroid surgery using a gasless transaxillary approach will advance the frontiers of minimally invasive endocrine surgery., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Background: Radiofrequency ablation (RFA) of liver tumors is associated with a risk of incomplete ablation or local recurrence., Methods: One hundred sixty-eight patients with 311 unresectable liver tumors were included. Effects of different variables on incomplete ablation and local recurrence were analyzed., Results: There were 132 hepatocellular carcinomas and 179 liver metastases. Tumor size was 24 (±13) mm. Two hundred twenty-six tumors were treated percutaneously, and 85 through open approach (associated with liver resection in 42 cases). There was no mortality. Major morbidity rate was 7%. Incomplete ablation and local recurrence rates were 14% and 18.6%. Follow-up was 29 months. On multivariate analysis, factors associated with incomplete ablation were tumor size (>30 mm vs ≤30 mm, P = .004) and approach (percutaneous vs open, P = .0001). Factors associated with local recurrence were tumor size (>30 mm vs ≤30 mm, P = .02) and patient age (>65 years vs ≤65 years, P = .05)., Conclusions: RFA is effective to treat unresectable liver tumors. However, there is a risk of incomplete ablation when percutaneously treating tumors >30 mm. When tumor ablation is completely achieved, the main factor associated with local recurrence is tumor size >30 mm., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Purpose: Several new minimally invasive techniques (mini-open, video-assisted, and endoscopic procedures) for parathyroidectomy have been described. However, totally endoscopic lateral approach parathyroidectomy (Henry technique) is not routinely performed., Methods: This is a prospective study of 200 consecutive patients that underwent totally endoscopic lateral parathyroidectomy., Results: Two hundred of 387 patients (52%) with primary hyperparathyroidism were included. Fifty-six patients (28%) were converted to open parathyroidectomy. Causes for conversion were lack of intraoperative localization (11%), difficult dissection (10%), bleeding (4%), failure of normalization of IOPTH results (2%), and other causes (1%). Gland localization (areas 1 to 2 versus area 3) and CaPTHus score (<3 versus ≥3) were not associated with the risk of conversion. Mean postoperative follow-up was 13 months, and 196 patients (98%) were cured., Conclusions: Totally endoscopic lateral approach can be proposed in more than half of the patients with good immediate results. Conversion rate remains important and may explain low acceptance rate of this technique.

Purpose: This prospective multicentre study assesses the usefulness of FDG PET/CT in characterizing and making the therapeutic decision concerning adrenal tumours that are suspicious or indeterminate in nature after conventional examinations (CE)., Methods: Seventy-eight patients (37 men, 41 women, 81 adrenal lesions) underwent FDG PET/CT after CE including CT scan, biological tests and optionally (131)I-metaiodobenzylguanidine (MIBG) and/or (131)I-norcholesterol scans. FDG adrenal uptake exceeding that of the liver was considered positive. PET results were not decisive. Surgery was discussed when at least one of the following criteria was found during CE: size >3 cm, spontaneous attenuation value >10 HU, heterogeneous aspect, abnormal MIBG or norcholesterol scan or hormonal hypersecretion., Results: Following the gold standard (histology analysis or >or=9 months follow-up), 49 lesions potentially qualified for surgery (malignant = 27, benign secreting = 22) and 32 benign non-secreting lesions did not. PET was negative in 97% of non-surgical lesions and positive in 73% of potentially surgical ones which included all the malignant lesions, except 3 renal cell metastases, and 12 of 22 benign secreting lesions. The negative predictive value for malignancy was 93% (41/44) and positive predictive value for detecting surgical lesions was 97% (36/37). A high FDG uptake (maximum standardized uptake value >or= 10) was highly predictive of malignancy., Conclusion: Adrenal FDG uptake is a good indicator of malignancy and/or of secreting lesions and should lead one to discuss surgery. If there is no prior history of poorly FDG-avid cancer, the absence of FDG uptake should avoid unnecessary removal of benign adrenal lesions.

With an incidence of 950,000 pregnancies per year in France, the likelihood of seeing one or more surgical abdominal diseases during pregnancy is high. The goal of this update was to describe the management of four different settings in the pregnant woman: colorectal cancer, laparoscopic surgery, gastrointestinal emergency surgery, and bariatric surgery., (Copyright © 2010. Published by Elsevier Masson SAS.)

Background: Patients are relying on the Internet with greater frequency to learn about diseases and make medical decisions. We hypothesized that there is a disparity between the perceptions of patients and those of surgeons regarding the quality of information about primary hyperparathyroidism on the Internet., Methods: Patients (n = 62) with primary hyperparathyroidism seen in endocrine surgery clinics in France and the United States responded to a survey regarding their use of the Internet to prepare for upcoming parathyroid surgery. A panel of endocrine surgeons reviewed the top "hits" retrieved from Web sites related to parathyroid disease. Sites were rated using a previously validated Web site quality scoring system., Results: A total of 75% of the American cohort and 53% of the French cohort used the Internet to prepare for parathyroid surgery. The majority of these patients reported that the information was "somewhat to very accurate." The panel of surgeons gave the Web sites an overall average qualitative score of 8.6 (53%)., Conclusion: Surgeons and patients have different perceptions as to what constitutes a high-quality Web site. As patients depend more on the Internet to prepare for parathyroid surgery, there is an opportunity and a clear need to create comprehensive, high-quality, patient-oriented Web sites on this topic.

Background: Primary hyperparathyroidism is associated with an increased cardiovascular morbidity and mortality. However, mechanisms underlying this association are currently unclear. As there is clear evidence of the independent role of aldosterone on the cardiovascular system, the aim of this study was to evaluate aldosterone levels in patients with primary hyperparathyroidism., Methods: A prospective study of 134 consecutive patients with primary hyperparathyroidism before and 3 months after parathyroidectomy., Results: Pre-operative serum aldosterone and parathyroid hormone (PTH) levels were correlated positively in all patients (.238; P = .005). In the 62 patients (46%) that were not on antihypertensive medications, this correlation was stronger (.441; P = .0003). In the 72 patients (54%) treated with at least 1 antihypertensive medication, no correlation between preoperative aldosterone and PTH serum levels was observed. By multivariate analysis, pre-operative PTH level (.409; P = .005) was an independent predictor of aldosterone. Pre-operative PTH level >100 ng/L was an independent predictor of abnormally elevated plasma aldosterone level (odds ratio 3.5; P = .01). At 3 months after parathyroidectomy, no correlation was observed between postoperative PTH and aldosterone levels., Conclusion: Aldosterone is correlated positively to preoperative PTH levels in patients with primary hyperparathyroidism. Aldosterone might be a key mediator of cardiovascular symptoms in patients with primary hyperparathyroidism.

This review is an update of the long-term follow-up of nutritional and metabolic issues following bariatric surgery, and also discusses the most recent guidelines for the three most common procedures: adjustable gastric bands (AGB); sleeve gastrectomy (SG); and roux-en-Y gastric bypass (GBP). The risk of nutritional deficiencies depends on the percentage of weight loss and the type of surgical procedure performed. Purely restrictive procedures (AGB, SG), for example, can induce digestive symptoms, food intolerance or maladaptative eating behaviours due to pre- or postsurgical eating disorders. GBP also has a minor malabsorptive component. Iron deficiency is common with the three types of bariatric surgery, especially in menstruating women, and GBP is also associated with an increased risk of calcium, vitamin D and vitamin B12 deficiencies. Rare deficiencies can lead to serious complications such as encephalopathy or protein-energy malnutrition. Long-term problems such as changes in bone metabolism or neurological complications need to be carefully monitored. In addition, routine nutritional screening, recommendations for appropriate supplements and monitoring compliance are imperative, whatever the bariatric procedure. Key points are: (1) virtually routine mineral and multivitamin supplementation; (2) prevention of gallstone formation with the use of ursodeoxycholic acid during the first 6 months; and (3) regular, life-long, follow-up of all patients. Pre- and postoperative therapeutic patient education (TPE) programmes, involving a new multidisciplinary approach based on patient-centred education, may be useful for increasing patients'long-term compliance, which is often poor. The role of the general practitioner has also to be emphasized: clinical visits and follow-ups should be monitored and coordinated with the bariatric team, including the surgeon, the obesity specialist, the dietitian and mental health professionals., (Copyright 2009 Elsevier Masson SAS. All rights reserved.)

Background: Primary hyperparathyroidism is an unusual cause of acute pancreatitis. The aim of this study was to analyse data from multiple centers concerning patients with primary hyperparathyroidism and associated acute pancreatitis and to analyze potential predictive factors., Methods: In this retrospective multicentric study, 19 patients were identified (Group A) with the associated diagnoses of acute pancreatitis and primary hyperparathyroidism. Their clinical data was compared to that of a control group of 65 patients (group B) with primary hyperparathyroidism without acute pancreatitis., Results: Age, parathormone levels and pathology (uni/multiglandular disease) were similar between the two groups. The mean plasma calcium level was significantly higher in group A (12.64 mg/100ml) than in group B patients without pancreatitis (11.28 mg/100ml) (p<0.0001)., Conclusion: This study confirms the causal relationship between primary hyperparathyroidism and acute pancreatitis. The degree of hypercalcemia may play an important role in this association. Calcium levels should be measured in all patients with acute pancreatitis.

Thyroid cancers are the most common endocrine cancer. Cervical lymph node metastases are observed in 20 to 60% of patients with papillary thyroid cancer. In 2008, no prospective randomized study has defined whether prophylactic central neck dissection should be performed during initial surgery for papillary thyroid cancer. Prophylactic lymph node dissection remains controversial. Pros and cons for routine lymph node dissection of the central cervical compartment are discussed in this review of the literature which includes data from international and French consensus conferences.

L. Brunaud Thyroid cancers are the most common endocrine cancer. Cervical lymph node metastases are observed in 20 to 60% of patients with papillary thyroid cancer. In 2008, no prospective randomized study has defined whether prophylactic central neck dissection should be performed during initial surgery for papillary thyroid cancer. Prophylactic lymph node dissection remains controversial. Pros and cons for routine lymph node dissection of the central cervical compartment are discussed in this review of the literature which includes data from international and French consensus conferences., (Copyright © 2008 Elsevier Masson SAS. All rights reserved.)

Background: Our aim was to determine the learning curve for robotic adrenalectomy and factors that influence operative time and cost., Methods: We prospectively evaluated of 100 consecutive patients who underwent robotic, unilateral, transperitoneal adrenalectomy., Results: The mean operative time for robotic-assisted adrenalectomy was 95 minutes and conversion rate was 5%. Pathology was aldosteronoma (n = 39), pheochromocytoma (n = 24), nonfunctional adenoma (n = 19), Cushing adenoma or hyperplasia (n = 16), and cyst (n = 2). Morbidity and mortality rates were 10% and 0%, respectively. The mean operative time decreased by 1 minute every 10 cases. Operative time improved more for junior surgeons than for senior surgeons (P = .006) after the first 50 cases. By multiple regression analysis, surgeon's experience (-18.9 +/- 5.5), first assistant level (-7.8 +/- 3.2), and tumor size (3 +/- 1.4) were independent predictors of operative time (P < .001 each). The robotic procedure was 2.3 times more costly than lateral transperitoneal laparoscopic adrenalectomy (euro4102 vs euro1799)., Conclusions: Surgeon experience, resident training level, and tumor size are important variables for robotic-assisted, unilateral adrenalectomy and should be taken into account when this approach is evaluated. Controlled studies need to be performed to show potential relevant clinical benefits that could balance costs.

Background: The purpose of this study was to evaluate the role of Internet on patients scheduled for bariatric procedures and the quality of information available on different websites., Methods: Between July 2003 to July 2005, patients undergoing bariatric surgical procedures completed a survey. Data were collected prospectively. One hundred valid surveys were returned. Independently, two bariatric surgeons evaluated available French and English websites using major search engines., Results: Forty-two of 100 patients (42%) sought information about bariatric surgery on the Internet. Seventy-four percent of these patients (n = 31/42) used search engines with 81% visiting less than ten websites. According to the patient's evaluation, 58% of the websites visited did not provide technical details of any surgical bariatric procedures, and only 61% provided information regarding postoperative weight loss. Furthermore, 58% of websites did not provide information about the laparoscopic approach, and 54% did not give any information on potential postoperative complications. Bariatric surgeon's evaluation was similar except for two differences: laparoscopic approach and postoperative weight loss information were discussed in 90% (p < 0.001) and 43% (p < 0.1) of visited websites, respectively., Conclusion: When the Internet was used to search for information about bariatric surgery, search engines were preferentially used but search duration was short. Available Internet websites can be considered as moderately reliable; however, 25% of visited websites contain misleading information. Comparison between patients and surgeons views showed that patients were effective in detecting misleading information.

Background: This study evaluates the perioperative outcomes of robotic-assisted adrenalectomy (RA) compared with lateral transperitoneal laparoscopic adrenalectomy (LA)., Methods: Prospective evaluation of 50 patients who underwent unilateral RA versus 59 patients who underwent unilateral LA., Results: RA was associated with lower blood loss (49 mL) but longer operative times (104 minutes) (P < .001). However, the difference in operative time was not significant after the learning curve of 20 cases. In patients with body mass index (BMI) > or = 30 kg/m(2), mean operative time was longer in the LA group (90 vs 78 minutes, P = .03) but not in the RA group. In patients with large tumors (> or = 55 mm), mean operative time was longer in the LA group (100 vs 80 minutes, P = .009) but not in the RA group. Conversion rate, morbidity, and hospital stay were similar in both groups., Conclusions: After a learning curve of 20 cases, RA has similar perioperative outcomes compared to lateral transperitoneal LA. Several criteria (previous laparoscopic expertise, first assistant's skill and tumor side) remain determinative on RA operative time.

The presence of distant metastases from differentiated thyroid carcinoma decreases the 10-year survival of patients by 50%. Bone metastases represent a frequent complication especially of follicular thyroid cancer and severely reduce the quality of life causing pain, fractures, and spinal cord compression. Diagnosis is established by correlating clinical suspicion with imaging. Imaging is essential to detect, localize, and assess the extension of the lesions and should be used in conjunction with clinical evidence. Bone metastases are typically associated with elevated markers of bone turnover, but these markers have not been evaluated in differentiated thyroid cancer. Skeletal and whole-body magnetic resonance imaging and fusion 2-deoxy-2-[18F]fluoro-D-glucose whole-body positron emission tomography/computed tomography (PET/CT) are the best anatomic and functional imaging techniques available in specialized centers. For well-differentiated lesions, iodine-PET scan combined (124)I-PET/CT is the newest imaging development and (131)I is the first line of treatment. Bisphosphonates reduce the complications rate and pain, alone or in combination with radioiodine, radionuclides, or external beam radiotherapy and should be employed. Surgery and novel minimally invasive consolidation techniques demand an appropriate patient selection for best results on a multimodal approach. Basic research on interactions between tumor cells and bone microenvironment are identifying potential novel targets for future more effective therapeutic interventions for less differentiated tumors.