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Background This nationwide retrospective study was undertaken to evaluate impact of hospital volume and influence of liver transplantation activity on postoperative mortality and failure to rescue after liver surgery. Methods This was a retrospective study of patients who underwent liver resection between 2011 and 2019 using a nationwide database. A threshold of surgical activities from which in-hospital mortality declines was calculated. Hospitals were divided into high- and low-volume centres. Main outcomes were in-hospital mortality and failure to rescue. Results Among 39 286 patients included, the in-hospital mortality rate was 2.8 per cent. The activity volume threshold from which in-hospital mortality declined was 25 hepatectomies. High-volume centres (more than 25 resections per year) had more postoperative complications but a lower rate of in-hospital mortality (2.6 versus 3 per cent; P < 0.001) and failure to rescue (5 versus 6.3 per cent; P < 0.001), in particular related to specific complications (liver failure, biliary complications, vascular complications) (5.5 versus 7.6 per cent; P < 0.001). Liver transplantation activity did not have an impact on these outcomes. Conclusion From more than 25 liver resections per year, rates of in-hospital mortality and failure to rescue declined. Management of specific postoperative complications appeared to be better in high-volume centres.

Resume Introduction La fistule anastomotique est la complication redoutee apres chirurgie colorectale. De nombreux travaux ont montre l’interet du dosage de la CRP en postoperatoire comme marqueur diagnostic precoce. Le seuil critique des marqueurs biologiques de l’inflammation doit-il rester le meme que la resection soit colique ou rectale ? Patients et methode Il s’agit d’une etude basee sur une cohorte constituee entre 2011 et 2014, incluant 497 patients avec une resection colorectale programmee. La proteine C-reactive et la pro-calcitonine ont ete mesurees tous les jours entre la veille et le 4e jour. Toutes les complications postoperatoires intra-abdominales ont ete considerees comme une fistule anastomotique. Les seuils de detection ont ete calcules a partir de l’aire sous la courbe ROC. Resultats Une complication septique intra-abdominale est survenue chez 16,9 % des operes d’une resection rectale contre 9,9 % apres colectomie (p = 0,03). Il n’existe pas de difference significative en termes de reponse inflammatoire postoperatoire entre les deux groupes en l’absence de complications, tant sur la CRP que la PCT. Apres resection rectale, la meilleure aire sous la courbe (AUC = 0,87) correspond a la CRP de j4 pour un seuil de 100 mg/L : sensibilite 83,3 %, une VPN 95,3 %. Pour les colons avec la meme CRP a 100 mg/L (AUC = 0,71), la sensibilite est de 63,6 % et la VPN de 93,9 %. Conclusion Malgre une chirurgie plus a risque, le seuil de detection de la fistule anastomotique apres chirurgie rectale reste le meme : CRP > 100 mg/L a j4.

Summary Introduction Anastomotic fistula is the most fearsome complication following colorectal surgery. Numerous studies have demonstrated the interest of postoperative CRP assay as an early diagnostic marker. Must the critical threshold for biological inflammatory markers remain the same, whether resection be colic or rectal? Patients and method This is a study based on a cohort constituted between 2011 and 2014, including 497 patients with planned colorectal resection. C-reactive protein and pro-calcitonin were measured daily from day before surgery to D4. All postoperative intra-abdominal complications were considered as an anastomotic fistula. Detection thresholds were calculated from the area under the ROC curve. Results An intra-abdominal septic complication occurred in 16.9% of the patients having undergone rectal resection vs. 9.9% of those having had colectomy (P = 0.03). In the absence of complications there was no significant difference between the two groups in terms of postoperative inflammatory response as determined by either CRP or PCT assay. Following rectal resection, optimal area under the curve (AUC = 0.87) corresponds to CRP on D4 for a threshold of 100 mg/L: sensitivity 83.3%, NPV 95.3%. For colons with the same CRP at 100 mg/L (AUC = 0.71): sensitivity 63.6%, NPV 93.9%. Conclusion Notwithstanding riskier surgery, the detection threshold for an anastomotic fistula following rectal surgery remains the same: CRP > 100 mg/L at D4.

Background FTR appears as a major cause of postoperative mortality (POM). Hospital volume has an impact on FTR in pancreatic surgery but no study has investigated this relationship more specifically in DP. Methods We analysed patients with DP between 2009 and 2018 through a nationwide database. FTR definition was mortality among patients who experiment major complications. The cutoff between high and low volume centers was 20 pancreatectomies per year. Results Some 10,632 patients underwent DP, 5048 (47.5%) were operated in 602 (95.4%) low volume centers and 5584 (52.5%) in 29 (4.6%) high volume centers. Overall FTR occurred in 11.2% of patients and was significantly reduced in high volume centers compared to low volume centers (10.2% vs 12.5%, p = 0.047). In multivariate analysis, surgery in a high volume center was a protective factor for POM (OR = 0.570, CI95% [0.505–0.643], p Conclusion Hospital volume has a positive impact on FTR in DP. Patients with higher risk of FTR are men, with high modified Charlson comorbidity index, malignant conditions and open procedures.

Resume Contexte Nous savons que l’inflammation est liee au pronostic du cancer colorectal et a l’apparition d’infections postoperatoires. Objectif Cette etude visait a comprendre la relation entre l’inflammation preoperatoire et le pronostic du cancer colorectal et a elucider si l’impact de l’inflammation sur le pronostic du cancer etait lie a un risque accru d’infection chirurgicale ou etait independant de celui-ci. Methodes Les patients ayant subi une chirurgie elective du cancer colorectal, entre novembre 2011 et avril 2014, ont ete inclus dans une base de donnees prospective (IMACORS). La proteine C-reactive (CRP) preoperatoire a ete collectee pour chaque patient. Les patients ont ete suivis selon les directives nationales francaises. Un seuil de CRP preoperatoire de 5 mg/L a ete choisi. Les caracteristiques cliniques ont ete comparees selon la CRP en utilisant le Chi2 test et le test de Mann–Whitney. La survie globale (SG) et la survie sans maladie (SSR) ont ete comparees par les courbes de Kaplan–Meier. Un modele de regression des risques proportionnels de Cox a ete applique pour effectuer une analyse multivariee des predicteurs de l'SG et du SSR. Resultats Un total de 254 patients a ete inclus. L’âge median etait de 68 ans. Le suivi median etait de 41,8 mois. La CRP mediane preoperatoire globale etait de 5 mg/L. La CRP preoperatoire etait significativement associee au statut N. Elle est significativement plus elevee chez les patients atteints de cancer du colon et chez les patients qui n’ont pas recu de traitement neoadjuvant. Une analyse multivariee a revele que la CRP preoperatoire est un facteur pronostique independant de la SG et de la SSR, respectivement (HR = 2,34 (1,26–4,31), p = 0,006 et HR = 1,83 (1,15–2,90), p = 0,01). Conclusion L’inflammation preoperatoire mesuree par la CRP est independamment liee a la survie globale et sans maladie du cancer colorectal.

Anastomotic leak results in increased morbidity and affects functional and oncological outcomes after colectomy. Measurement of C-reactive protein (CRP) allows early detection of anastomotic leaks. The aim of this study was to evaluate the benefit to the patient of earlier diagnosis and management of anastomotic leaks, namely avoiding takedown of the anastomosis.Patients with an anastomotic fistula after elective colorectal surgery from 2010 to 2020 were included. Three periods were defined according to progressive adherence to the CRP protocol in our department. A comparison was made between the periods 'before' (2010-2013) and 'after' (2016-2020) in terms of morbidity, mortality, anastomotic salvage, days spent in hospital within the first postoperative month, timely adjuvant chemotherapy and anastomotic stenosis.Out of 2655 elective colorectal operations, 171 patients presented with an anastomotic leak and 123 patients were included in the study. In univariate analysis, patients in the 'after' group had fewer severe complications (Clavien-Dindo Grade III to IV, 66.7% vs. 56.9; p = 0.017); the difference did not reach significance regarding timely postoperative chemotherapy (p = 0.058) and anastomotic stenosis (p = 0.682). In both, univariate and multivariate analysis, the 'after' period increased the chances of preserving the anastomosis (OR = 2.37 [1.08-5.17]) and increased the number of days out of hospital (p = 0.0002).A CRP-based protocol for the screening of anastomotic leaks after colorectal surgery was related to increased anastomotic conservation, a decreased impact and severity of the leak and a shorter length of hospital stay.

Fast-track protocols are increasingly used after digestive surgery. After esophagectomy, the gravity and the fear of anastomotic leak may be an obstacle to generalization of such protocols. C-reactive protein (CRP) might be a reliable tool to identify patients at low risk of anastomotic leak after esophagectomy, so that they can be safely included in a fast-track program. The aim of our retrospective bicentric study is to evaluate the interest of C-reactive protein measurement for the early diagnosis of anastomotic leak after esophagectomy.Patients having undergone Ivor-Lewis procedure between January 2009 and September 2017 were included in this bicentric retrospective study. CRP values were recorded between postoperative day 3 (POD 3) and postoperative day 5 (POD 5). All postoperative complications were recorded, and the primary endpoint was anastomotic leak.We included 585 patients. Among them, 241 (41.2%) developed infectious complications and 69 patients (11.8%) developed anastomotic leak. CRP had the best predictive value on POD 5 (AUC = 0.74; 95% CI: 0.67-0.81). On POD 5, a cut-off value of 130 mg/L yielded a sensitivity of 87%, a specificity of 51%, and a negative predictive value of 96% for the detection of anastomotic leak.CRP may help in identifying patients at very low risk of anastomotic leak after esophagectomy. Patients with CRP values 130 mg/L on POD 5 can safely undertake an enhanced recovery protocol.

Objectives Our objective was to identify hospitals with unusual mortality rates for major pancreatectomies over a period of ten years using 30-day mortality data from the French national database. Methods Data for all patients who underwent pancreatectomy were extracted from the national medico-economic database (Programme de Médicalisation des Systèmes d'Information). To identify quality outliers for each hospital, the observed-to-expected 30-day mortality rates were used as a quality indicator. Results A total of 19 494 patients underwent a major pancreatectomy in France between January 2009 and December 2018. The overall 30-day mortality rate was 4.8% (n = 944). For the 2009–2014 period, the funnel plot showed that 10 of the 176 hospitals lie outside the central 95% region and 7 lie outside the central 99.8% region. For the 2015–2018 period, out of 176 hospitals, 6 lie outside the central 95% region and 2 lie outside the central 99.8% region. The change in standardized mortality ratios between 2009–2014 and 2015–2018 testing for differences from the overall change, they were there 4 hospitals lie outside the central 95% region and 0 lie outside the central 99.8% region. Conclusion Over time, the improvement in hospital quality was weak. This study suggests that there is a pressing need to reorganize the supply of care for pancreatic surgery in France.

Resume Introduction Les eventrations sont des complications frequentes des laparotomies. Pour leur reparation, il est recommande d’utiliser une prothese synthetique qui permet de renforcer la paroi et de prevenir les recidives. Cependant, l’utilisation de la prothese en milieu contamine comporte un risque d’infection de l’implant. Dans ce contexte sont apparues les protheses biologiques, puis les biosynthetiques, resistant en milieu contamine, voire infecte, mais au prix d’une resorption qui peut laisser le doute sur la survenue d’une recidive a ce moment. Les protheses biosynthetique en P4HB sont des treillis resorbables en 12–18 mois. Le but de cette etude etait d’evaluer le taux de recidive a 1 an de la reparation avec une prothese en P4HB. Methodes Tous les patients operes entre 2016 et 2018 au CHU de Dijon pour une eventration avec utilisation d’une prothese Phasix® ont ete inclus. Le suivi a ete complet jusqu’a un an avec realisation d’un scanner abdominopelvien systematique. Les complications postoperatoires ont ete recueillies. Resultats Un total de 29 patients a ete inclus dans l’etude (55,2 % de femmes), avec un IMC moyen de 30,25 kg/m2. Dix-neuf protheses ont ete posees en retromusculaire et 10 en intraperitoneal. Les complications a un mois etaient principalement classees Clavien-Dindo I et II (61,1 %). Aucune explantation ni infection chronique n’a ete detectee. La duree moyenne de sejour etait de 11,5 jours. Le taux de recidive a 1 an etait de 10,3 %. Conclusion A 1 an d’une reparation d’eventration complexe avec champ operatoire contamine, les protheses lentement resorbables en P4HB presentent un taux de recidive de 10,3 %. Aucune complication grave du site operatoire n’est apparue. Un suivi plus long sur une plus grande cohorte est necessaire afin de confirmer la place de cette prothese dans cette indication.

Aim To assess postoperative complications and control of hormone secretions following pancreatoduodenectomy (PD) performed on multiple endocrine neoplasia type 1 (MEN1) patients with duodenopancreatic neuroendocrine tumors (DP-NETs). Background The use of PD to treat MEN1 remains controversial, and evaluating the right place of PD in MEN1 disease makes sense. Methods Thirty-one MEN1 patients from the Groupe d’étude des Tumeurs Endocrines MEN1 cohort who underwent PD for DP-NETs between 1971 and 2013 were included. Early and late postoperative complications, secretory control and overall survival were analyzed. Results Indication for surgery was: Zollinger–Ellison syndrome (n = 18; 58%), nonfunctioning tumor (n = 9; 29%), insulinoma (n = 2; 7%), VIPoma (n = 1; 3%) and glucagonoma (n = 1; 3%). Mean follow-up was 141 months (range 0–433). Pancreatic fistulas occurred in 5 patients (16.1%), distant metastases in 6 (mean onset of 43 months; range 13–110 months), postoperative diabetes mellitus in 7 (22%), and pancreatic exocrine insufficiency in 6 (19%). Five-year overall survival was 93.3% [CI 75.8–98.3] and ten-year overall survival was 89.1% [CI 69.6–96.4]. After a mean follow-up of 151 months (range 0–433), the biochemical cure rate for MEN-1 related gastrinomas was 61%. Conclusion In MEN1 patients, pancreatoduodenectomy can be used to control hormone secretions (gastrin, glucagon, VIP) and to remove large NETs. PD was found to control gastrin secretions in about 60% of cases.

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.

Una rottura diaframmatica e spesso integrata in un politrauma, di cui e un criterio di gravita. Essa puo essere difficile da evidenziare in fase acuta, in quanto i suoi segni sono poco specifici. La diagnostica per immagini, che visualizza gli organi risaliti ma piu difficilmente la rottura stessa, puo essere carente. Cosi, essa e spesso non diagnosticata in fase acuta e puo manifestarsi tardivamente. Una volta diagnosticata, il trattamento chirurgico e la sutura per via addominale, spesso preferita alla via toracica, che ha delle indicazioni limitate. La via laparoscopica e una via d’accesso da privilegiare in un traumatizzato stabile.

Introduction : La sleeve gastrectomie (SG) est devenue la technique de chirurgie bariatrique la plus réalisée en France. Cependant, les causes d’échec sont peu connues, et le volume gastrique (VG) pourrait y avoir un rôle. Le but de cette étude est donc d’analyser le lien entre le volume gastrique à un an et le succès pondéral. Patients et méthodes : Tous les patients obèses ayant bénéficié d’une SG entre septembre 2015 et juin 2017 ont bénéficié d’une volumétrie gastrique scanographique un an après la chirurgie. Le pourcentage d’excès de poids perdu à un an était mesuré pour évaluer le résultat pondéral et rechercher un lien avec le VG résiduel. Résultats : Cent soixante-huit patients consécutifs ont été inclus avec seulement sept perdus de vue (4,17 %). Le taux de succès de la SG à un an s’élevait à 73,9 %. Le sexe féminin et l’IMC préopératoire inférieur à 50 kg/m2 étaient des facteurs prédictifs de succès puisqu’il y avait 85,7 % de femmes dans le groupe succès contre 66,7 % dans le groupe échec (p = 0,007), et l’IMC moyen était de 43,7 ± 5,3 kg/m2 en cas de succès contre 46,7 ± 6,1 kg/m2 en cas d’échec (p = 0,003). Le VG était significativement plus petit chez les femmes (185,92 ± 95,83 cm3 vs 244,75 ± 134,06 cm3, p = 0,005) et chez les patients de moins de 40 ans (177,0 ± 85 cm3 vs 215 ± 119,8 cm3, p = 0,02). Le VG résiduel moyen était de 186,42 cm3 dans le groupe ayant un bon résultat pondéral et de 226,43 cm3 dans le groupe en échec de perte pondérale (p = 0,17). Conclusion : Le résultat pondéral à un an après sleeve gastrectomie n’est pas statistiquement lié au volume gastrique résiduel.

CONTEXT: Peritoneal closure with a barbed suture during laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is a controversial subject due to the risk of postoperative intestinal adhesions and occlusions formed by this type of suture. This risk, however, was only reported in several case reports. The purpose of this study is to determine the incidence of postoperative intestinal obstructions related to the use of barbed suture materials in laparoscopic hernia repair (TAPP). PATIENTS AND METHODS: We included all patients that underwent laparoscopic TAPP inguinal hernia repair between October 2012 and October 2017. All peritoneal closures were accomplished using absorbable barbed sutures. Operative data were collected in a dedicated database and analyzed retrospectively. RESULTS: Only 3 out of the 320 patients included (0.9%) presented with an early postoperative intestinal obstruction and required further surgery. Two of the three patients (0.6%) were found to have intestinal incarceration in the peritoneal defects initially created during the hernia repair. However, the last patient had an intestinal volvulus due to adhesions formed with the barbed suture. None of the patient characteristics collected were significant risk factors for developing postoperative intestinal obstructions. CONCLUSION: In this study, peritoneal closure using barbed suture material did not increase the risk of early postoperative intestinal obstruction, in comparison to other suture materials reported in the literature. The use of barbed absorbable sutures for peritoneal closure during laparoscopic TAPP seems to be safe when sutures are cut short and covered by the peritoneum.

Background To report our preliminary experience with preoperative portal vein embolization (PVE) using liquid ethylene vinyl alcohol (EVOH) copolymer. Methods Retrospectively review of patients with primary or secondary liver malignancies scheduled for extensive hepatectomy after the induction of future liver remnant (FLR) hypertrophy by right or left PVE with EVOH as the only embolic agent between 2014 and 2018 at two academic centers. Cross-sectional imaging liver volumetry data obtained before and 3-6 weeks after PVE were used to assess the FLR volume (FLRV) increase, degree of FLR hypertrophy and the FLR kinetic growth rate (KGR). Results Twenty-six patients (17 males; mean age, 58.7±11 years; range, 32-79 years) were included. The technical and clinical success rate was 100%. PVE produced adequate FLR hypertrophy in all patients. Embolization occurred in all targeted portal branches and in no non-target vessels. The %FLRV increased by 52.9%±32.5% and the degree of FLR hypertrophy was 16.7%±6.8%. The KGR was 4.4%±2.0% per week. Four patients experience minor complications after PVE which resolved with symptomatic treatment. The resection rate was 84.5%. One patient died during surgery for reasons unrelated to PVE. Conclusions Preoperative PVE with EVOH copolymer is feasible, safe, and effective in inducing FLR hypertrophy.

Summary Background The addition of hyperthermic intraperitoneal chemotherapy (HIPEC) to cytoreductive surgery has been associated with encouraging survival results in some patients with colorectal peritoneal metastases who were eligible for complete macroscopic resection. We aimed to assess the specific benefit of adding HIPEC to cytoreductive surgery compared with receiving cytoreductive surgery alone. Methods We did a randomised, open-label, phase 3 trial at 17 cancer centres in France. Eligible patients were aged 18–70 years and had histologically proven colorectal cancer with peritoneal metastases, WHO performance status of 0 or 1, a Peritoneal Cancer Index of 25 or less, and were eligible to receive systemic chemotherapy for 6 months (ie, they had adequate organ function and life expectancy of at least 12 weeks). Patients in whom complete macroscopic resection or surgical resection with less than 1 mm residual tumour tissue was completed were randomly assigned (1:1) to cytoreductive surgery with or without oxaliplatin-based HIPEC. Randomisation was done centrally using minimisation, and stratified by centre, completeness of cytoreduction, number of previous systemic chemotherapy lines, and timing of protocol-mandated systemic chemotherapy. Oxaliplatin HIPEC was administered by the closed (360 mg/m2) or open (460 mg/m2) abdomen techniques, and systemic chemotherapy (400 mg/m2 fluorouracil and 20 mg/m2 folinic acid) was delivered intravenously 20 min before HIPEC. All individuals received systemic chemotherapy (of investigators' choosing) with or without targeted therapy before or after surgery, or both. The primary endpoint was overall survival, which was analysed in the intention-to-treat population. Safety was assessed in all patients who received surgery. This trial is registed with ClinicalTrials.gov , NCT00769405 , and is now completed. Findings Between Feb 11, 2008, and Jan 6, 2014, 265 patients were included and randomly assigned, 133 to the cytoreductive surgery plus HIPEC group and 132 to the cytoreductive surgery alone group. After median follow-up of 63·8 months (IQR 53·0–77·1), median overall survival was 41·7 months (95% CI 36·2–53·8) in the cytoreductive surgery plus HIPEC group and 41·2 months (35·1–49·7) in the cytoreductive surgery group (hazard ratio 1·00 [95·37% CI 0·63–1·58]; stratified log-rank p=0·99). At 30 days, two (2%) treatment-related deaths had occurred in each group.. Grade 3 or worse adverse events at 30 days were similar in frequency between groups (56 [42%] of 133 patients in the cytoreductive surgery plus HIPEC group vs 42 [32%] of 132 patients in the cytoreductive surgery group; p=0·083); however, at 60 days, grade 3 or worse adverse events were more common in the cytoreductive surgery plus HIPEC group (34 [26%] of 131 vs 20 [15%] of 130; p=0·035). Interpretation Considering the absence of an overall survival benefit after adding HIPEC to cytoreductive surgery and more frequent postoperative late complications with this combination, our data suggest that cytoreductive surgery alone should be the cornerstone of therapeutic strategies with curative intent for colorectal peritoneal metastases. Funding Institut National du Cancer, Programme Hospitalier de Recherche Clinique du Cancer, Ligue Contre le Cancer.

SCOPUS: ar.j, info:eu-repo/semantics/published

Background Staple line reinforcement during surgery may decrease morbidity or reduce the risk of staple line leaks and bleeding. There is debate regarding the benefit, safety, and best form of reinforcement. This case series characterizes the safety of a stapler with a pre-attached buttress in bariatric surgeries. Methods This prospective, multicenter, post-market study examined the use of stapler reloads with built in reinforcement material. The primary endpoint is the incidence of reported device-related adverse events up to 30 days after laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (SG) surgeries. Specific outcomes included bleeding (≥50 mL), leaks, and 30-day readmissions. Outcomes A total of 51 patients (19 RYGB, 32 SG) were assessed after exclusion criteria were applied. Intraoperatively, no leaks or bleeding related to the staple line occurred. Four patients (8% overall, 3 RYGB, 1 SG) experienced bleeding unrelated to the staple line and staple line intervention, in these cases, was not required. Four subjects (8%, all SG) required readmission and each were attributed as unrelated to the investigational device. No unanticipated device-related events were observed. Two adverse events (bleeding) occurred post-operatively that were attributed as possibly related to the device; both were endoscopically managed. Conclusions This study demonstrates that there were no serious safety concerns from the AEs observed related to reinforced reload use during or in the 30-day course after 51 common bariatric procedures in a multicenter setting. Trial registration The study was registered with clinicaltrials.gov (NCT02500537). Thoracic subjects from this study are described in a separate manuscript.

Summary Background We know that inflammation is related to colorectal cancer prognosis and to the onset of postoperative infections. Objective This study aimed to understand the relationship between preoperative inflammation and the prognosis of colorectal cancer and to elucidate whether the impact of inflammation on cancer prognosis was related to an increased risk of surgical infection or was independent of it. Methods Patients who underwent elective colorectal cancer surgery between November 2011 and April 2014 were included in a prospective database (IMACORS). Preoperative c reactive protein was collected for each patient. Patients were followed up according to the French national guidelines. A cut-off of preoperative CRP of 5 mg/L was chosen. Clinical characteristics were compared according to CRP using Chi2 and Mann–Whitney tests. The Overall Survival (OS) and Disease-Free-Survival (DFS) were compared by Kaplan–Meier curves. A Cox proportional hazards regression model was applied to perform a multivariate analysis of OS and DFS's predictors. Results A total of 254 patients were included. The median age was 68 years old. The median follow up was 41.8 months. The overall median preoperative CRP was 5 mg/L. Preoperative CRP was significantly associated with N status; CRP being significantly higher among patients with colonic cancer and with patients who didn’t receive a neoadjuvant treatment. Multivariate analyse revealed that preoperative CRP is an independent prognostic factor of OS and DFS respectively (HR = 2.34 (1.26–4.31), P = 0.006 and HR = 1.83 (1.15–2.90), P = 0.01). Conclusion Preoperative inflammation measured by CRP is independently related with overall and disease-free survival of colorectal cancer.

Background The optimal surgical procedure for duodenal gastrointestinal stromal tumors (D-GISTs) remains poorly defined. Pancreaticoduodenectomy (PD) allows for a wide resection but is associated with a high morbidity rate. Objectives The aim of this study was to compare the short- and long-term outcomes of PD versus limited resection (LR) for D-GISTs and to evaluate the role of tumor enucleation (EN). Methods In this retrospective European multicenter cohort study, 100 patients who underwent resection for D-GIST between 2001 and 2013 were compared between PD (n = 19) and LR (n = 81). LR included segmental duodenectomy (n = 47), wedge resection (n = 21), or EN (n = 13). The primary objective was to evaluate disease-free survival (DFS) between the groups, while the secondary objectives were to analyze the overall morbidity and mortality, radicality of resection, and 5-year overall survival (OS) and recurrence rates between groups. Furthermore, the short- and long-term outcomes of EN were evaluated. Results Baseline characteristics were comparable between the PD and LR groups, except for a more frequent D2 tumor location in the PD group (68.3% vs. 29.6%; p = 0.016). Postoperative morbidity was higher after PD (68.4% vs. 23.5%; p < 0.001). OS (p = 0.70) and DFS (p = 0.64) were comparable after adjustment for D2 location and adjuvant therapy rate. EN was performed more in American Society of Anesthesiologists (ASA) stage III/IV patients with tumors < 5 cm and was associated with a 5-year OS rate of 84.6%, without any disease recurrences. Conclusions For D-GISTs, LR should be the procedure of choice due to lower morbidity and similar oncological outcomes compared with PD. In selected patients, EN appears to be associated with equivalent short- and long-term outcomes. Based on these results, a surgical treatment algorithm is proposed.

Background Anthropometric data as prognostic factors of colorectal cancer are promising but contradictory. The aim of this study was to assess the preoperative body composition profiles as predictive factors for postoperative, oncologic, and inflammation outcomes. Objectives We sought to assess the impact of body composition profiles on short- and long-term outcomes and on postoperative inflammatory response in a clinical setting for patients following curative intent surgery for colorectal cancer. Setting University hopsital Methods We analyzed 122 patients from a prospective cohort (IMACORS) with colorectal cancer undergoing curative-intent surgery from 2011 to 2014. Musculature, total, visceral, and subcutaneous adiposity were measured from a preoperative CT scan and outcomes were compared between profiles. Results Preoperative myopenia was an independent predictive factor of recurrence (HR = 3.3 95% CI = 1.6–6.9; P = .002) while subcutaneous adiposity was a protective factor (HR = .4 95% CI = .2–.9; P = .03). No anthropometric measurement was predictive of overall survival and postoperative intra abdominal infection was not determined by body composition profiles. Preoperative and D4 CRP levels were significantly higher in patients with subcutaneous adiposity. Conclusions Myopenia and subcutaneous adiposity seemed to have independent and opposite prognostic effects on recurrence. Muscle mass loss may represent a modifiable risk factor while the amount of subcutaneous adipose tissue reflects an energetic storage favorable to face this pathologic process.

To compare our experience with N-butyl cyanoacrylate glue as the primary embolic agent versus other embolic agents for transcatheter arterial embolization (TAE) in refractory peptic ulcer bleeding and to identify factors associated with early rebleeding and 30-day mortality. Retrospective study of 148 consecutive patients comparing the clinical success rate in 78 patients managed with Glubran®2 N-butyl cyanoacrylate metacryloxysulfolane (NBCA-MS) alone or with other agents and 70 with other embolic agents only (coils, microspheres, ethylene-vinyl alcohol copolymer, or gelatin sponge) at a university center in 2008–2019. Univariate and multivariate logistic regression analyses were done to identify prognostic factors. The technical success rate was 95.3% and the primary clinical success was 64.5%. The early rebleeding and day-30 mortality rates were 35.4% and 21.3%, respectively. Rebleeding was significantly less common with than without Glubran®2 (OR, 0.47; 95% CI, 0.22–0.99; p = .047) and significantly more common with coils used alone (OR, 20.4; 95% CI, 10.13–50.14; p = .024). The only other factor independently associated with early rebleeding was having two or more comorbidities (OR, 20.14; 95% CI, 10.01–40.52; p = .047). Day-30 mortality was similar in the two treatment groups. A lower initial hemoglobin level was significantly associated with higher day-30 mortality (OR, 10.38; 95% CI, 10.10–10.74; p = .006). Fluoroscopy time was significantly shorter with Glubran®2 (20.8 ± 11.5 min vs. 35.5 ± 23.4 min, p = .002). Both groups (Glubran®2 vs. other agents) had similar rates of overall complications (10.7% vs. 9.1%, respectively, p = .786). Glubran®2 NBCA-MS as the primary agent allowed for faster and better clinical success compared to other embolic agents when used for TAE to safely stop refractory peptic ulcer bleeding. • Choice of embolic agent for arterial embolization of refractory peptic ulcer bleeding is still debated. We compared our experience with N-butyl cyanoacrylate (NBCA) glue vs. other embolic agents. • The use of Glubran®2 NBCA glue in the endovascular management of refractory peptic ulcer bleeding was significantly faster and more effective, and at least as safe compared to other embolic agents. • NBCA glue offers several advantages compared to other embolic agents and provides rapid hemostasis when used for arterial embolization to treat refractory peptic ulcer bleeding. It should be the first-line therapy.

Summary Chyloperitoneum is a potential complication of omega-loop gastric bypass caused by internal herniation. Chronic compression of the mesentery leads to chylous extravasation that can mimic peritonitis.

Digestive cancer is of concern because of its frequency and severity with an increasing older median age of onset. The purpose of this study was to describe in a well-defined population presenting with non-metastatic digestive cancer the frequency of surgical resection and outcomes according to age.We analyzed 7760 patients with a non-metastatic digestive cancer, recorded in the Burgundy population-based digestive cancer registry between 2009 and 2017. There were 3506 non-colorectal cancers and 4254 colorectal cancers with 3292 colon and 962 rectal cancers. The frequency of surgical resection was analyzed according to age (classified into four categories70, [70-80[, [80-85[, and ≥85), sex, comorbidities and obesity. Postoperative mortality at 30 and 90 days was determined according to age, sex, comorbidity, obesity, location, surgery R0 or not. The 5-year survival study included 2952 patients with colorectal cancer, non-metastatic and who benefited from an R0 resection.Overall, 64% of the patients with M0 digestive cancer underwent a surgical resection, varying from 31% for Non colorectal Digestive cancers to 94% for colon site. The percentage of patients operated on for a resectable disease decreases from 71% before age 70 to 43% from age 85. Age and comorbidities were the main criteria influencing the probability of resection. At 30 days, postoperative mortality was 3%, all localizations and ages combined. At 90 days, this rate was 5%. In patients over 85 years old it gradually increases from 7% at 30 days and to 10% at 90 days. A man under 70 years of age has a net survival of 0.88 at 5 years, and 0.91 for a woman. For a man between 70 and 80 years old, it decreases to 0.81 and to 0.66 from 80 years old. In women, net survival is 0.87 between 70 and 80 years of age at 5 years, then drops to 0.75 from age 80.Our study shows a drop in access to surgery at different pivotal ages depending on the tumor location. This sudden drop in the resection rate is not justified by the increase in mortality with age, which is linear. In addition, the expected benefits of surgery are significant, with a net survival, mainly after the 1st year, of the same order as for younger patients. Age by itself should not be the only criterion in the medical decision. The challenge is to detect and treat the comorbidities that worsen the operative risk and the prognosis. There are few data on the management of digestive cancers specifically in the elderly. Our study shows that access to surgery is strongly linked to age and this in a non-linear way, whereas the expected benefits of surgery are significant, of the same order as for younger patients. Age itself should not be the only criterion in the medical decision.

Background Surgical resection remains the only curative option for pancreatic adenocarcinoma. Despite recent improvements in medical imaging, unresectability is still often discovered at the time of surgery. It is essential to identify unresectable patients preoperatively to avoid unnecessary surgery. High serum CA 19-9 levels have been suggested as a marker of unresectability but considered inaccurate in patients with hyperbilirubinemia. Aim of the study To evaluate CA 19-9 serum levels as a predictor of unresectability of pancreatic adenocarcinomas with a special focus on jaundiced patients. Methods All patients presenting with histologically-confirmed pancreatic adenocarcinoma and having serum CA 19-9 levels available prior to any treatment were included in this retrospective study. The relationship between serum concentrations of CA 19–9 and resectability was studied by regression analysis and theROC curves obtained. A cut-off value of CA 19–9 was calculated. In jaundiced patients, a CA 19–9 adjusted for bilirubinemia was also evaluated. Results Of the 171 patients included, 49 (29%) were deemed resectable and 122 (71%) unresectable. Altogether, 93 patients (54%) had jaundice. The area under the ROC curve for CA 19–9 as a predictor of resectability was 0.886 (95%CI:[0.832–0.932]); in jaundiced patients it was 0.880 (95% CI [0.798–0.934]. A cut-off in CA 19–9 at 178 UI/mlyielded 85% sensitivity, 81% specificity and 91% positive predictive value for resectability. There was no correlation between the levels of bilirubin and CA 19–9 (r = 0.149). Conclusion Serum CA 19–9 is a good predictive marker of unresectability of pancreatic adenocarcinoma, even in jaundiced patients. CA 19-9 levels over 178 UI/ml strongly suggest unresectable disease.

Resume Contexte L’utilisation de drains chirurgicaux fait debat mais ils restent frequemment utilises, que ce soit de facon preventive ou curative. Leur migration par rapport a la position souhaitee lors de l’intervention chirurgicale est un phenomene peu etudie. Le but de cette etude a ete d’etudier l’incidence du deplacement des drains chirurgicaux parmi les patients operes d’une chirurgie digestive abdominale. Patients et methodes Nous avons inclus dans cette etude tous les patients ayant eu un scanner postoperatoire precoce (avant mobilisation des drains) apres chirurgie digestive abdominale, entre janvier 2013 et avril 2016 au CHU de Dijon. Les donnees pre-, per- (nombre, type et position des drains) et postoperatoires (imagerie et evolution) ont ete revues retrospectivement et colligees dans une base de donnees. Resultats Parmi les 125 patients inclus, 35 (28 %) d’entre eux presentaient une migration d’au moins un drain par rapport a son emplacement lors de l’intervention. Parmi les 207 drains, 41 (19,8 %) s’etaient deplaces. La morbidite postoperatoire n’etait pas plus elevee chez les patients chez lesquels le drain avait bouge ( p = 0,51). Aucun des facteurs pre- et peroperatoires etudies ne s’est revele etre un facteur de risque significatif de migration. Conclusion La migration des drains est tres frequente apres chirurgie abdominale. Cette migration ne semble pas avoir eu de consequence clinique dans notre experience. Lorsqu’un benefice est attendu de l’utilisation de drains chirurgicaux, une fixation intraperitoneale semble necessaire.

Las hernias diafragmaticas raras estan representadas por las hernias retrocostoxifoideas o de Morgagni-Larrey y las hernias de las cupulas o de Bochdalek. Las hernias de Morgagni-Larrey, mas frecuentes en adultos, suelen ser asintomaticas o responsables de sintomas poco especificos, pero pueden causar un cuadro agudo desde el nacimiento. Las hernias de Bochdalek se manifiestan sobre todo en el periodo neonatal por un cuadro muy sintomatico, mientras que suelen tolerarse bien en adultos. El diagnostico de las hernias diafragmaticas se basa en la radiografia de torax y la tomografia computarizada (TC) con contraste baritado. El tratamiento es quirurgico debido al riesgo de estrangulacion. Puede realizarse por un acceso toracico o abdominal, en la mayoria de los casos por tecnicas minimamente invasivas, y consiste en una reduccion del contenido herniario, una reseccion del saco y un cierre del orificio herniario con o sin utilizacion de una protesis.

RAS mutation status is an important prognostic factor after resection of liver metastases (LiM) from colorectal cancer (CRC). The prognostic significance of RAS after resection of lung (LuM) and peritoneal (PM) metastases from CRC is unknown. Between 2005 and 2014, all consecutive patients with known RAS status who underwent potentially curative resection for LiM, LuM, or PM were evaluated. A total of 720 patients with known RAS status underwent resection of LiM (n = 468), LuM (n = 102), and PM (n = 150). RAS mutations were identified in 63 and 58% of patients with LuM and PM, respectively, compared with 41% of patients with LiM (p

Cette etude retrospective evalue la faisabilite et la morbimortalite de l’assistance robotique pour realiser un bypass gastrique avec une anse en Y montee en precolique comparee a la voie laparoscopique. Elle compare les 100 premiers by-pass avec assistance robotique aux 100 premiers by-pass par laparoscopie d’un meme operateur. Il n’y a pas de difference de duree operatoire ou de morbimortalite entre les deux groupes. L’assistance robotique pour realiser un bypass gastrique est faisable et fiable, meme lors de la periode d’apprentissage.

Resume Introduction Les concentrations seriques de proteine C reactive (CRP) en deca d’un seuil predefini entre le 3e et le 5e jour postoperatoire sont un marqueur fiable de l’absence de complication infectieuse apres chirurgie colorectale. Cependant, la strategie a mettre en place en cas de CRP elevee n’est pas codifiee. Le but de ce travail etait d’analyser l’utilite du scanner dans cette situation au sein d’une cohorte prospective de chirurgie colorectale reglee. Methodes Entre novembre 2011 et avril 2015, les patients ayant une CRP > 125 mg/L au 4e jour postoperatoire d’une resection colorectale reglee dans l’un des 2 centres participants ont ete inclus prospectivement dans une base. Toutes les complications survenues pendant les 30 j suivant l’intervention, leur mode de diagnostic, prise en charge et evolution ont ete recueillies. La realisation d’un scanner entre le 4e et le 6e jour guide par la seule elevation de la CRP, en l’absence de tout autre signe clinique, a ete etudiee pour evaluer ainsi sa rentabilite diagnostique. Des analyses uni- et multivariees ont ete realisees pour identifier les facteurs de risque d’infection postoperatoire. Resultats Au total, 174 patients ont ete inclus : 56 (32,1 %) ont eu un scanner entre le 4e et le 6e jour, qui a permis de detecter une complication postoperatoire dans 55,4 % des cas. Les patients n’ayant pas eu de scanner avaient des valeurs de CRP plus basses (163 vs 185,5, p = 0,02). Parmi les 118 patients n’ayant pas eu de scanner, 50,8 % ont presente une complication infectieuse a terme. La sensibilite du scanner guide par la CRP etait de 76,7 % et la valeur predictive negative de 78,8 %. Conclusion En presence d’une CRP elevee au 4e jour postoperatoire un scanner abdomino-pelvien doit etre realise. Un resultat normal n’elimine pas formellement l’existence d’une complication intra-abdominale. En cas de persistance de l’inflammation dans les deux jours suivants, une reprise chirurgicale systematique doit etre comparee a un nouveau scanner dans le cadre d’un protocole.

IF 7.641; International audience; B cells are involved in immune thrombocytopenia (ITP) pathophysiology by producing antiplatelet auto-antibodies. However more than a half of ITP patients do not respond to B cell depletion induced by rituximab (RTX). The persistence of splenic T follicular helper cells (TFH) that we demonstrated to be expanded during ITP and to support B cell differentiation and antiplatelet antibody-production may participate to RTX inefficiency. Whereas it is well established that the survival of TFH depends on B cells in animal models, nothing is known in humans yet. To determine the effect of B cell depletion on human TFH, we quantified B cells and TFH in the spleen and in the blood from ITP patients treated or not with RTX. We showed that B cell depletion led to a dramatic decrease in splenic TFH and in CXCL13 and IL-21, two cytokines predominantly produced by TFH. The absolute count of circulating TFH and serum CXCL13 also decreased after RTX treatment, whatever the therapeutic response. Therefore, we showed that the maintenance of TFH required B cells and that TFH are not involved in the inefficiency of RTX in ITP.

Resume La presence d’une hernie interne lors d’un bypass en omega peut etre responsable d’un chyloperitoine du fait d’une compression chronique du mesentere entrainant une extravasation de chyle pouvant mimer une peritonite.

Background Several multicenter randomized controlled trials comparing laparoscopy and conventional open surgery for colon cancer have demonstrated that laparoscopic approach achieved the same oncological results while improving significantly early postoperative outcomes. These trials included few elderly patients, with a median age not exceeding 71 years. However, colon cancer is a disease of the elderly. More than 65% of patients operated on for colon cancer belong to this age group, and this proportion may become more pronounced in the coming years. In current practice, laparoscopy is underused in this population. Methods The CELL (Colectomy for cancer in the Elderly by Laparoscopy or Laparotomy) trial is a multicenter, open-label randomized, 2-arm phase III superiority trial. Patients aged 75 years or older with uncomplicated colonic adenocarcinoma or endoscopically unresectable colonic polyp will be randomized to either colectomy by laparoscopy or laparotomy. The primary endpoint of the study is overall postoperative morbidity, defined as any complication classification occurring up to 30 days after surgery. The secondary endpoints are: 30-day and 90-day postoperative mortality, 30-day readmission rate, quality of surgical resection, health-related quality of life and evolution of geriatric assessment. A 35 to 20% overall postoperative morbidity rate reduction is expected for patients operated on by laparoscopy compared with those who underwent surgery by laparotomy. With a two-sided α risk of 5% and a power of 80% (β = 0.20), 276 patients will be required in total. Discussion To date, no dedicated randomized controlled trial has been conducted to evaluate morbidity after colon cancer surgery by laparoscopy or laparotomy in the elderly and the benefits of laparoscopy is still debated in this context. Thus, a prospective multicenter randomized trial evaluating postoperative outcomes specifically in elderly patients operated on for colon cancer by laparoscopy or laparotomy with curative intent is warranted. If significant, such a study might change the current surgical practices and allow a significant improvement in the surgical management of this population, which will be the vast majority of patients treated for colon cancer in the coming years. Trial registration ClinicalTrials.gov NCT03033719 (January 27, 2017).

BackgroundHeated intraperitoneal chemotherapy (HIPEC) is currently performed using an external circuit including a heating device and a pump. Available devices have several drawbacks in terms of costs, technique (flow surges due to blocked tubes) and staff safety, hindering a wider use. In a previous preclinical study conducted in animals, we placed a heating wire within the abdomen to achieve and maintain hyperthermia. Our results showed this technique is safe and effective. The present pilot study was conceived as the first use of such a device in humans, aiming to confirm its safety and efficacy.MethodsThis was a pilot study designed to include 13 patients undergoing HIPEC. Two sets of the prototype were placed within the abdominal cavity, one in the supramesocolic and one in the inframesocolic space. The target temperature was 42–43 °C during 30–90 min according to the protocol defined for each patient. The time to set up, heat and dismantle was measured. All complications were recorded during the first postoperative year and evaluated by an independent committee.ResultsNine women and four men were included. The median time to set on the device was 25 min. The target temperature was obtained in a median of 14 min and maintained uniform and homogeneously distributed within the abdomen for the scheduled duration. A permanent stirring of the viscera was performed. No thermal injury or device-related complications were observed. There were two anastomotic leaks (only one requiring reoperation), two hemoperitoneum requiring reoperation, one evisceration and one gastroparesia.ConclusionsA heating cable within the peritoneal cavity can achieve safe, simple, fast and efficient HIPEC.