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Introduction: Stereotactic MR-guided Adaptive RadioTherapy (SMART) is a novel process to treat pancreatic tumors. We present an update of the data from our prospective registry of SMART for pancreatic tumors. Materials and methods: After the establishment of the SMART indication in a multidisciplinary board, we included all patients treated for pancreatic tumors. Primary endpoints were acute and late toxicities. Secondary endpoints were survival outcomes (local control, overall survival, distant metastasis free survival) and dosimetric advantages of adaptive process on targets volumes and OAR. Results: We included seventy consecutive patients in our cohort between October 2019 and April 2022. The prescribed dose was 50 Gy in 5 consecutive fractions. No severe acute SMART related toxicity was noted. Acute and late Grade ≤ 2 gastro intestinal were low. Daily adaptation significantly improved PTV and GTV coverage as well as OAR sparing. With a median follow-up of 10.8 months since SMART completion, the median OS, 6-months OS, and 1-year OS were 20.9 months, 86.7% (95% CI: (75–93%), and 68.6% (95% CI: (53–80%), respectively, from SMART completion. Local control at 6 months, 1 year, and 2 years were, respectively, 96.8 % (95% CI: 88–99%), 86.5 (95% CI: 68–95%), and 80.7% (95% CI: 59–92%). There was no grade > 2 late toxicities. Locally Advanced Pancreatic Cancers (LAPC) and Borderline Resectable Pancreatic Cancers (BRPC) patients (52 patients) had a median OS, 6-months OS, and 1-year OS from SMART completion of 15.2 months, 84.4% (95% CI: (70–92%)), and 60.5% (95% CI: (42–75%)), respectively. The median OS, 1-year OS, and 2-year OS from initiation of induction chemotherapy were 22.3 months, 91% (95% CI: (78–97%)), and 45.8% (95% CI: (27–63%)), respectively. Twenty patients underwent surgical resection (38.7 % of patients with initially LAPC) with negative margins (R0). Conclusion: To our knowledge, this is the largest series of SMART for pancreatic tumors. The treatment was well tolerated with only low-grade toxicities. Long-term OS and LC rates were achieved. SMART achieved high secondary resection rates in LAPC patients.

International audience; OBJECTIVE: Defining robust and standardized outcome references for distal pancreatectomy (DP) by using Benchmark analysis. BACKGROUND: Outcomes after DP are recorded in medium or small-sized studies without standardized analysis. Therefore, the best results remain uncertain. METHODS: This multicenter study included all patients undergoing DP for resectable benign or malignant tumors in 21 French expert centers in pancreas surgery from 2014 to 2018. A low-risk cohort defined by no significant comorbidities was analyzed to establish 18 outcome benchmarks for DP. These values were tested in high-risk, minimally invasive and benign tumor cohorts. RESULTS: 1188 patients were identified and 749 low-risk patients were screened to establish Benchmark cut-offs. Therefore, Benchmark rate for mini-invasive approach was ≥q36.8%. Benchmark cut-offs for postoperative mortality, major morbidity grade ≥q3a and clinically significant pancreatic fistula rates were 0%, ≤q27% and ≤q28%, respectively. The benchmark rate for readmission was ≤q 16%. For patients with pancreatic adenocarcinoma, cut-offs were ≥q75%, ≥q69.5% and ≥q66% for free resection margins (R0), 1-year disease free-survival and 3-year overall survival, respectively. The rate of mini-invasive approach in high-risk cohort was lower than the Benchmark cut-off (34.1% vs. ≥q36.8%). All Benchmark cut-offs were respected for benign tumor group. The proportion of benchmark cases was correlated to outcomes of DP. Centers with a majority of low-risk patients had worse results than those operating complex cases. CONCLUSION: This large-scale study is the first benchmark analysis of DP outcomes and provides robust and standardized data. This may allow for comparisons between surgeons, centers, studies, and surgical techniques.

International audience; The obese patient is at risk of perioperative complications including difficult airway access (intubation, difficult or impossible ventilation), and postextubation acute respiratory failure due to the formation of atelectases or to airway obstruction. The association of obstructive sleep apnoea syndrome (OSA) with obesity is very common, and induces a high risk of per and postoperative complications. Preoperative OSA screening is crucial in the obese patient, as well as its specific management: use of continuous positive pre-, per- and postoperative pressure. For any obese patient, the implementation of difficult intubation protocols and the use of protective ventilation (low tidal volume 6–8 mL/kg of ideal body weight, moderate positive end-expiratory pressure of 10 cmH20, recruitment manoeuvres in absence of contra-indications), with morphine sparing and semi-seated positioning as much as possible are recommended, associated with a close postoperative monitoring. The dosage of anaesthetic drugs is usually based on the ideal body weight or the adjusted body weight and then titrated, except for succinylcholine that is dosed according to the total body weight. Monitoring of neuromuscular blockers should be used where appropriate, as well as monitoring of the depth of anaesthesia, especially when total intravenous anaesthesia is used in association with neuromuscular blockers. The occurrence of intraoperative awareness is indeed more frequent in the obese patient than in the non-obese patient. Appropriate prophylaxis against venous thromboembolism and early mobilisation are recommended, if possible included in an early rehabilitation protocol, to further reduce postoperative complications.

International audience; Background: We previously showed that embolization of portal inflow and hepatic vein (HV) outflow (liver venous deprivation, LVD) promotes future liver remnant (FLR) volume (FLR-V) and function (FLR-F) gain. Here, we compared FLR-V and FLR-F changes after portal vein embolization (PVE) and LVD.Methods: This study included all patients referred for liver preparation before major hepatectomy over 26 months. Exclusion criteria were: unavailable baseline/follow-up imaging, cirrhosis, Klatskin tumor, two-stage hepatectomy. 99mTc-mebrofenin SPECT-CT was performed at baseline and at day 7, 14 and 21 after PVE or LVD. FLR-V and FLR-F variations were compared using multivariate generalized linear mixed models (joint modelling) with/without missing data imputation.Results: Baseline FLR-F was lower in the LVD (n=29) than PVE group (n=22) (P

There are no specific guidelines for ventral hernia management in Crohn’s disease (CD) patients. We aimed to assess the risk of septic morbidity after mesh repair in CD. This was a retrospective multicentre study comparing CD and non-CD patients undergoing mesh repair for ventral hernia (primary or incisional hernia). Controls were matched 1:1 for the presence of a stoma, history of surgical sepsis, hernia size and Ventral Hernia Working Group (VHWG) score. All demographic, pre-, intra- and postoperative data were retrieved, including long-term data. We included 234 patients, with 114 CD patients. Both groups had comparable VHWG scores (p = 0.12), hernia sizes (p = 0.11), ASA scores ≥ 3 (p = 0.70), body mass index values (p = 0.14), presence of stoma (CD 21.9% vs. controls 15%, p = 0.16), history of sepsis (14% vs. 6.7%, p = 0.23), rates of malnutrition (4.4% vs. 1.7%, p = 0.46), rates of incisional hernia (93% vs. 95%, p = 0.68) and concomitant procedures (18.4% vs. 11.7%, p = 0.12). CD patients carried a higher risk of postoperative septic morbidity (18.4% vs. 5%, p = 0.001), entero-prosthetic fistula (7% vs. 0, p

International audience; Background & aims: Pancreatic ductal adenocarcinoma (PDAC) is associated with the highest incidence of venous thromboembolism (VTE) of any cancer type. However, little is known about risk factors for VTE or its outcomes in patients with PDAC.Methods: We collected data from a prospective, observational study performed at multiple centers in France from May 2014 through November 2018 (the Base Clinico-Biologique de l'Adénocarcinome Pancréatique [BACAP] study) linked to a database of patients with a new diagnosis of PDAC of any stage. Data were collected from 731 patients at baseline and during clinical follow-up or in the event of symptoms. The primary endpoint was the onset of VTE during follow-up. The secondary endpoints were progression-free survival (PFS) and overall survival (OS) times.Results: During a median follow-up of 19.3 months, 152 patients (20.79%) developed a VTE. The median time from PDAC diagnosis to the onset of VTE was 4.49 months. Cumulative incidence values of VTE were 8.07% (95% confidence interval [CI], 6.31-10.29) at 3 months and 19.21% (95% CI, 16.27-22.62) at 12 months. In multivariate analysis, PDAC primary tumor location (isthmus vs head: hazard ratio [HR], 2.06; 95% CI, 1.09-3.91; P = .027) and stage (locally advanced vs resectable or borderline: HR, 1.66; 95% CI, 1.10-2.51, P = .016; metastatic vs resectable or borderline: HR, 2.50; 95% CI, 1.64-3.79; P < .001) were independent risk factors for the onset of VTE. Patients who developed VTE during follow-up had shorter times of PFS (HR, 1.74; 95% CI, 1.19-2.54; P = .004) and OS (HR, 2.02; 95% CI, 1.57-2.60; P < .001).Conclusion: In an analysis of data from the BACAP study, we found that frequent and early onsets of VTE after diagnoses of PDAC are associated with significant decreases in times of PFS and OS. Studies are needed to determine whether primary prophylaxis of VTE in patients with PDAC will improve morbidity and mortality related to VTE. (ClinicalTrials.gov, Number: clinicaltrials.gov as number NCT02818829).

Consequences and complications of bariatric surgery. Bariatric surgery has a functional role (improvement of quality of life), a prevention role (increase in life expectancy, reduction of risk of cancer and cardiovascular disease) and a curative role (remission of diabetes mellitus, obstructive sleep apnea syndrome and arterial hypertension). The laparoscopic approach for bariatric surgery led to a major reduction of postoperative morbi-mortality and promotes its expansion with 49 000 procedures in 2015 (French PMSI data). Types and rates of complications after bariatric surgery vary according to the procedure. The efficiency of each technique is closely related to its morbi-mortality rate. This concept explains the disparity concerning the choice of the adequate procedure for the patient according to the bariatric team. The risk/benefits balance evaluation must be analyzed case-by-case by each specialist of the multidisciplinary bariatric staff and explained to the patients before final decision. This preoperative period (6-12 months) is crucial to select good candidates for bariatric surgery and contributes to the reduction of postoperative complications. A multidisciplinary surveillance for life is mandatory to prevent and treat late complications of bariatric surgery related to undernutrition.Conséquences et complications de la chirurgie de l’obésité. La chirurgie de l’obésité peut être qualifiée de fonctionnelle (amélioration de la qualité de vie), préventive (allongement de la durée de vie des patients, diminution du risque de cancer ou de pathologies cardiovasculaires), et curative (rémission du diabète de type 2, du syndrome d’apnées du sommeil, de l’hypertension artérielle). Grâce à l’avènement des techniques laparoscopiques qui a permis de diminuer de manière importante la morbidité des différentes opérations, elle a connu un essor extraordinaire ces dernières années, avec environ 49 000 actes opératoires réalisés en 2015 (données PMSI). Les complications de ce type d’opérations, qui doivent être réalisées dans des centres experts, varient en fonction de la complexité de la procédure. Plus une technique est efficace, plus le taux de morbi-mortalité est élevé. Cette constatation explique en partie la disparité, trouvée notamment en France, dans le choix de l’opération suivant les équipes pluridisciplinaires. L’évaluation du rapport bénéfices-risques doit être analysée et expliquée au patient par les différents professionnels de santé intervenant dans la décision collégiale délivrée au cours d’une réunion de concertation pluridisciplinaire. Ce chemin clinique préopératoire, qui varie obligatoirement de 6 à 12 mois suivant les cas, joue un rôle prépondérant dans la sélection des bons candidats et de ce fait dans la diminution du risque de survenue de complications en phase per- ou postopératoire. Un suivi pluridisciplinaire spécialisé régulier du patient est indispensable à vie, quelle que soit la procédure réalisée afin de prévenir et de traiter les complications plus tardives de la chirurgie de l’obésité liées à la dénutrition.

La majorité des patients atteints de la maladie de Crohn (MC) ont recours à la chirurgie au cours de l’évolution de leur maladie, avec un taux de complication supérieur à celui de la population générale. Le but de ce travail était d’analyser l’effet d’une pré-habilitation préopératoire (PP) sur la morbidité postopératoire des patients ayant des facteurs de risques (FDR) de complication, avant la réalisation d’une résection iléocæcale (RIC) pour MC.Matériels et méthodes : 159 patients opérés d’une RIC avec anastomose en un temps pour MC ont été inclus entre janvier 2010 et mars 2020. Les patients ont été répartis en 2 groupes selon qu’ils avaient reçu (n=75) ou non (n=84) une PP (support nutritionnel, antibiothérapie ou drainage d’un abcès, arrêt ou décroissance des traitements corticoïdes en cours).Résultats : il n’y avait pas de différence significative concernant les complications anastomotiques ou les complications globales à 90 jours entre les groupes pré-habilités ou non. La PP permettait d’améliorer significativement le taux moyen d’albuminémie (p

Introduction : la chirurgie cœlioscopique a connu un développement fulgurant sur ces vingt dernières années et est devenue la norme dans de nombreuses interventions. Cependant elle tend à être limitée dans des cas de chirurgies plus complexes et morbides comme la duodénopancréatectomie céphalique en raison de la proximité de vaisseaux majeurs et d'une reconstruction digestive complexe. De nombreux articles semblent montrer une faisabilité de ce geste. Nous avons retracé dans cette étude le début de notre expérience au CHU de Montpellier. L'objectif principal était l'évaluation de la morbi-mortalité des DPC laparoscopiques comparée au gold standard par voie ouverte.Matériel et méthode : il s'agissait d'une étude monocentrique rétrospective reprenant les 28 premiers patients opérés d'une DPC par voie cœlioscopique comparés à 62 patients opérés par voie ouverte avant la première résection cœlioscopique.Résultats : les deux groupes étaient comparables sur l'âge, les antécédents, l'indication opératoire, le groupe LPD présentait des tumeurs de plus petite taille 24,5 mm contre 32,7 mm dans le groupe OPD (p = 0,048). Il n'y avait pas de différence sur la mortalité, sur la fistule pancréatique, la survenue d'hémorragie et les pertes sanguines peropératoires, sur la reprise chirurgicale, et sur le temps de séjour. En revanche le taux de fistule biliaire était plus élevé dans le groupe LPD 21% vs 1,6% (p < 0,01). La qualité de résection était similaire dans les deux groupes sur les marges et le nombre de ganglions prélevés. Le temps opératoire était plus élevé dans le groupe LPD en moyenne 350 min dans le groupe contre 206 min dans le groupe OPD (p < 0,001).Conclusion : la DPC présente une morbi-mortalité similaire dans les deux voies d'abord avec un temps opératoire plus long en cœlioscopie. Elle est une voie d'abord sûre pour la réalisation de cette chirurgie à condition d'une bonne sélection des patients.