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Several scoring systems predict risks of clinically relevant postoperative pancreatic fistula after pancreatectomy, but none have emerged as the gold standard. This study aimed to evaluate the accuracy of postoperative day 1 drain amylase and serum C-reactive protein levels in predicting clinically relevant postoperative pancreatic fistula compared with intraoperative pancreatic characteristics.Patients who underwent pancreatectomy between 2017 and 2019 were included prospectively. Cutoff values were determined using receiver operating characteristic curves, and a score combining postoperative day 1 drain amylase and serum C-reactive protein was tested in a multivariate logistic regression model to evaluate clinically relevant postoperative pancreatic fistula risk.A total of 274 pancreatic resections (182 pancreaticoduodenectomies and 92 distal pancreatectomies) were included. The pancreatic gland texture was "soft" in 47.8% (n = 131), and 55.8% (n = 153) had a small size main pancreatic duct (≤3 mm). Clinically relevant postoperative pancreatic fistula occurred in 58 patients (21.2%). Drain amylase ≥1,000 UI/L and serum C-reactive protein ≥90 mg/L were identified as the optimal cutoffs to predict clinically relevant postoperative pancreatic fistula. On multivariate analysis these cutoffs were independent predictors of clinically relevant postoperative pancreatic fistula after both pancreaticoduodenectomies (drain amylase: P.001, serum C-reactive protein: P = .006) and distal pancreatectomies (drain amylase: P = .009, serum C-reactive protein: P = .001). The postoperative day 1 "90-1000" model, a 2-value score relying on these cutoffs, significantly (P.001) outperformed intraoperative pancreatic parenchymal characteristics in predicting clinically relevant postoperative pancreatic fistula after both pancreaticoduodenectomies and distal pancreatectomies. A postoperative day 1 "90-1000" score = 0 had a negative predictive value of 97% and 94%, respectively, after pancreaticoduodenectomy and distal pancreatectomies.A combined score relying on postoperative day 1 values of drain amylase and serum C-reactive protein levels was accurate in predicting risks of clinically relevant postoperative pancreatic fistula after pancreatectomy.

Delayed post-pancreatectomy hemorrhage (PPH) is still one of the most dreaded complications after pancreatic surgery. Its management is now focused on percutaneous endovascular treatments (PETs). Between 2013 and 2019, 307 patients underwent pancreatic resection. The first endpoint of this study was to determine predictive factors of delayed PPH. The second endpoint was to describe the management of intra-abdominal abscesses (IAA). The third endpoint was to identify risk factors of bleeding recurrence after PET. Patients were divided into two cohorts: A retrospective analysis was performed (“cohort 1,” “learning set”) to highlight predictive factors of delayed PPH. Then, we validated it on a prospective maintained cohort, analyzed retrospectively (“cohort 2,” “validation set”). Second and third endpoints studies were made on the entire cohort. In cohort 1, including 180 patients, 24 experienced delayed PPH. Multivariate analysis revealed that POPF diagnosis on postoperative day (POD) 3 (p=0.004) and IAA (p=0.001) were independent predictive factors of delayed PPH. In cohort 2, association of POPF diagnosis on POD 3 and IAA was strongly associated with delayed PPH (area under the curve [AUC] 0.80; 95% confidence interval [CI] [0.59–0.94]; p=0.003). Concerning our second endpoint, delayed PPH occurred less frequently in patients who underwent postoperative drainage procedure than in patients without IAA drainage (p=0.002). Concerning our third endpoint, a higher body mass index (BMI) (p=0.027), occurrence of postoperative IAA (p=0.030), and undrained IAA (p=0.011) were associated with bleeding recurrence after the first PET procedure. POPF diagnosis on POD 3 and intra-abdominal abscesses are independent predictive factors of delayed PPH. Therefore, patients presenting an insufficiently drained POPF leading to intra-abdominal abscess after pancreatic surgery should be considered as a high-risk situation of delayed PPH. High BMI, occurrence of postoperative IAA, and undrained IAA were associated with recurrence of bleeding after PET.

The aim of the study was to compare histological features, postoperative outcomes, and long-term prognostic factors after pancreaticoduodenectomy for distal cholangiocarcinoma and pancreatic ductal adenocarcinoma. From 2005 to 2017, 188 pancreaticoduodenectomies (pancreatic ductal adenocarcinoma n = 151, distal cholangiocarcinoma n = 37) were included. Postoperative outcomes were compared after matching on pancreatic gland texture and main pancreatic duct size. Matching according to tumor size, lymph node invasion and resection margin was used to compare overall and disease-free survival. Distal cholangiocarcinoma patients had more often “soft” pancreatic gland (P = 0.002) and small size main pancreatic duct (P = 0.001). Pancreatic ductal adenocarcinoma patients had larger tumors (P = 0.009), and higher lymph node ratio (P = 0.017). Severe morbidity (P = 0.023) and clinically relevant pancreatic fistula (P = 0.018) were higher in distal cholangiocarcinoma patients. After matching on gland texture and main pancreatic duct diameter, clinically relevant postoperative pancreatic fistula was still more frequent in distal cholangiocarcinoma patients (P = 0.007). Tumor size > 20 mm was predictive of impaired overall survival (P = 0.024) and disease-free survival (P = 0.003), tumor differentiation (P = 0.027) was predictive of impaired overall survival. Survival outcomes for distal cholangiocarcinoma and pancreatic ductal cholangiocarcinoma were similar after matching patients according to tumor size, lymph node invasion and resection margin. Long-term outcomes after pancreaticoduodenectomy for distal cholangiocarcinoma and pancreatic ductal adenocarcinoma patients are similar. Postoperative course is more complicated after pancreaticoduodenectomy for distal cholangiocarcinoma than pancreatic ductal adenocarcinoma. After pancreaticoduodenectomy, patients with distal cholangiocarcinoma and pancreatic ductal adenocarcinoma have similar long-term oncological outcomes.

The surgical difficulty and postoperative outcomes of laparoscopic liver resection (LLR) are related to the size of the cut liver surface. This study assessed whether the estimated parenchymal transection surface area could predict intraoperative difficulty and postoperative outcomes. LLRs performed between 2008 and 2018, for whom a preoperative CT scan was available for 3D review, were included in the study. The area of scheduled parenchymal transection was measured on the preoperative CT scan and cut-off values that could predict intraoperative difficulty were analyzed. 152 patients who underwent left lateral sectionectomy (n = 27, median estimated area 30.1 cm2 [range 16.6–65.9]), left/right hepatectomy (n = 17 and n = 70, 76.8 cm2 [range 43.9–150.9] and 72.2 cm2 [range 39.4–124.9], respectively), right posterior sectionectomy (n = 7, 113.3 cm2 [range 102.1–136.3]), central hepatectomy (n = 11, 109.1 cm2 [range 66.1–186.1]) and extended left/right hepatectomy (n = 6 and n = 14, 115.3 cm2 [range 92.9–128.9] and 50.7 cm2 [range 13.3–74.9], respectively) were included. An estimated parenchymal transection surface area ≥ 100 cm2 was associated with significant increase in operative time (AUC 0.81, 95% CI [0.70, 0.93], p

We evaluated the intuition of expert pancreatic surgeons, in predicting the associated risk of pancreatic resection and compared this “intuition” to actual operative follow-up. The objective was to avoid major complications following pancreatic resection, which remains a challenge. From January 2015 to February 2018, all patients who were 18 years old or more undergoing a pancreatic resection (pancreaticoduodenectomy [PD], distal pancreatectomy [DP], or central pancreatectomy [CP]) for pancreatic lesions were included. Preoperatively and postoperatively, all surgeons completed a form assessing the expected potential occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF: grade B or C), postoperative hemorrhage, and length of stay. Preoperative intuition was assessed for 101 patients for 52 PD, 44 DP, and 5 CP cases. Overall mortality and morbidity rates were 6.9% (n = 7) and 67.3% (n = 68), respectively, and 38 patients (37.6%) developed a POPF, including 27 (26.7%) CR-POPF. Concordance between preoperative intuition of CR-POPF occurrence and reality was minimal, with a Cohen’s kappa coefficient (κ) of 0.175 (P value = 0.009), and the same result was obtained between postoperative intuition and reality (κ = 0.351; P

In laparoscopic major hepatectomy, analysis of outcomes according to specimen extraction site remains poorly described. The aim was to compare postoperative outcomes according to specimen extraction site. From 2000 to 2017, all laparoscopic major hepatectomies were reviewed and postoperative outcomes were analyzed according to specimen extraction site: subcostal (Group 1), midline (Group 2), or suprapubic (Group 3) incision. Among 163 patients, 15 (9.2%) belonged to Group 1, 49 (30.1%) in Group 2, and 99 (60.7%) in Group 3. The proportion of right-sided, left-sided, or central hepatectomies, mortality, and overall and severe complications were comparable between groups. Group 1 had larger tumors (61 vs. 38 vs. 47 mm; P = 0.014), higher operative time (338 vs. 282 vs. 260 min; P

Objective The present study analyzes nutrition support in a group of patients undergoing colorectal surgery managed by nutritional requirement software compared to a group of consecutive patients undergoing colorectal surgery with conventional nutrition Materials and Methods A total of 485 patients were treated between January 2000 and January 2013 with colorectal resection. Outcomes (mortality, morbidity according to Clavien classification, length of hospital stay, type of colorectal disease) in a group of patients who received nutrition support through software (SG) were compared to those in a previous series, control group (CG) with conventional nutrition support Results Of the patients, 59.6% were men and the median age of the population was 68.2 years (range, 19–95 years), with no difference between the 2 groups. There were significantly more malnourished patients in the SG group (SG 63.8% versus 45.2% CG; P < 0.0001). The overall mortality was 2.1% lower in the SG group, but without a significant difference (SG 0.7% versus 2.7% CG). There were more severe stage III to IV complications according to Clavien classification in the SG group (SG 10.7 GC versus 17% NS), with significantly greater collections (SG 8% versus 16.9% CG; P = 0.015) and greater anastomotic leaks (SG 4% versus 13.9% CG; P < 0.001). The median hospital stay was lower in the SG group (SG 12 days versus 15 days CG; P = 0.049). Conclusion The proposed software could contribute to optimizing the strategy of nutritional support in hospitalized patients.

The laparoscopic approach is widely accepted as the procedure of choice for abdominal surgery. However, laparoscopic liver resection (LLR) has advanced slowly due to the significant learning curve (LC), and only few publications have dealt with advanced training in LLR. Two reviewers conducted systematic research through MEDLINE and EMBASE with combinations of the following keywords: (learning curve OR teaching OR training OR simulation OR education) AND (liver OR hepatic) AND (laparoscopic OR laparoscopy). Robotic-assisted, hand-assisted and hybrid LLRs were excluded. Nineteen studies were retrieved. Overall, the level of evidence was low. Thirteen articles assessed the LC during real-life LLR, and six articles focussed on simulation and training programmes in LLR. The LC in minor LLR comprised 60 cases overall, and 15 cases for standardised left lateral sectionectomy. For major LLR (MLLR), the LC was 50 cases for most studies, but was reported to be 15–20 cases in more recent studies, provided MLLR is performed progressively in selected patients. However, there was heterogeneity in the literature regarding the number of minor LLRs required before MLLR, with 60 minor LLRs reported as the minimum. Six studies showed a potential benefit of simulation and training programmes in this field. The gradual implementation of LLR combined with simulation-based training programmes could reduce the clinical impact of LC. The LC in LLR is a long process, and MLLR should be gradually implemented under the supervision of experienced surgeons. Training outside the operating room may reduce the LC in real-life situations.

To improve the laparoscopic surgical dissection, the aim of the study was to assess the safety of burst of high-pressure COThe first step was to define the settings use of the PD device ensuring no GE. Successive procedures were conducted by laparotomy: cholecystectomy, the PD was placed 10 mm deep in the liver and the PD was directly introduced into the lumen of the inferior vena cava. Different PD flow rates of 5, 10, and 15 mL/s were used. The second step was to assess the safety of the device (PD group) during a laparoscopic dissection task (cystic and hepatic pedicles dissection, cholecystectomy and right nephrectomy) in comparison with the use of a standard laparoscopic hook device (control group). PD flow rate was 10 mL/s and consecutive burst of high-pressure COIn the first step (n = 17 swine), no GE occurred during cholecystectomy regardless of the PD flow rate used. When the PD was placed in the liver or into the inferior vena cava, no severe or fatal GE occurred when a burst of high-pressure COThe 5-mm laparoscopic PD appears to be free from CO

Splenic vessel involvement occurs frequently in pancreatic ductal adenocarcinoma (PDAC) of the body and the tail (B/T) but the impact on survival is unknown. We assessed the influence of radiological and pathologic involvement of splenic artery (p-SA +) and vein (p-SV +) on patient outcomes after distal pancreatectomy (DP) for PDAC. From 2013 to 2019, all DP for PDAC in five centers were included. Factors associated with overall (OS) and disease-free (DFS) survival were identified. Among the 76 patients included, 5 (6.6%) had p-SA + only, 11 (14.5%) had p-SV + only, and 24 (31.6%) had both p-SA + and p-SV + . The preoperative CT-scan accuracy to predict p-SV + and p-SA + was high (sensitivity: 91.4% and 82.8%, respectively; negative predictive value: 89.7% and 88.3%, respectively). The 5-year OS and DFS rates were 3.9% and 8.3%, respectively. Multivariate analysis identified splenic vessel involvement (i.e., p-SA + or p-SV + , or both p-SA + and p-SV +) as the only independent factor influencing DFS (HR 4.04; 95% CI [1.22–13.44], p = 0.023). Tumor size ≥ 30 mm was the only independent factor influencing OS (HR 4.04; 95% CI [1.26–12.95], p = 0.019) and was associated with a high risk of p-SA + (p = 0.001) and p-SV + (p

No specific performance assessment scales have been reported in laparoscopic liver resection. This study aimed at developing an objective scale specific for the assessment of technical skills for wedge resection in anterior segments (WRAS) and left lateral sectionectomy (LLS). A laparoscopic liver skills scale (LLSS) was developed using a hierarchical task analysis. A Delphi method obtained consensus among five international experts on relevant steps that should be included into the LLSS for assessment of operative performances. The consensus was predefined using Cronbach’s alpha > 0.80. A semi-structured review extracted 15 essential subtasks for full laparoscopic WRAS and LLS for evaluation in the Delphi survey. Two rounds of the survey were conducted. Three over 15 subtasks did not reach the predefined level of consensus. Based on the expert’s comments, 13 subtasks were reformulated, 4 subtasks were added, and a revised skills scale was developed. After the 2nd round survey (Cronbach’s alpha 0.84), 19 subtasks were adopted. The LLSS was composed of three main parts: patient positioning and intraoperative preparation (task 1 to 8), the core part of the WRAS and LLS procedure (tasks 9 to 14), and completion of procedure (task 15 to 19). The LLSS was developed for measuring the skill set for the education of safe and secure laparoscopic WRAS and LLS procedures in a dedicated training program. After validation, this scale could be also used as an assessment tool in the operating room and extrapolated as an operative roadmap to other complex procedures.

Background: To identify predictive factors for reoperation because of anastomotic leakage (AL) after colectomy. Methods: Between 2007 and 2016, all patients who developed AL following right or left...

The prognosis of patients with pancreatic cancer remains poor and novel therapeutic targets are required urgently. Treatment resistance could be due to the tumour microenvironment, a desmoplastic stroma consisting of cancer-associated fibroblasts and tumour-infiltrating lymphocytes (TILs). The aim of the study was to evaluate the prognostic value of TILs and cancer-associated fibroblasts (CAFs) in pancreatic cancer of the body and tail.Using tissue microarray from resected left-sided pancreatic cancer specimens, the immunohistochemistry of TILs (cluster of differentiation (CD) 45, CD3, CD4, FoxP3 and CD8), CAFs (vimentin and α-smooth muscle actin (αSMA)) and functional markers (PD-L1 and Ki-67) was examined, and the association with disease-free (DFS) and overall (OS) survival investigated using a computer-assisted quantitative analysis. Patients were classified into two groups, with low or high levels or ratios, using the 75th percentile value as the cut-off.Forty-three patients were included in the study. Their median DFS and OS were 9 and 27 months respectively. A high CD4/CD3 lymphocyte ratio was associated with poorer DFS (8 months versus 11 months for a low ratio) (hazard ratio (HR) 2·23, 95 per cent c.i. 1·04 to 4·61; P = 0·041) and OS (13 versus 27 months respectively) (HR 2·62, 1·11 to 5·88; P = 0·028). A low αSMA/vimentin ratio together with a high CD4/CD3 ratio was correlated with poorer outcomes. No significant association was found between Ki-67, PD-L1 and survival.In patients with resected left-sided pancreatic cancer, a tumour microenvironment characterized by a high CD4/CD3 lymphocyte ratio along with a low αSMA/vimentin ratio is correlated with poorer survival.El pronóstico del cáncer de páncreas sigue siendo malo y se requieren nuevas dianas terapéuticas de forma urgente. La resistencia al tratamiento podría ser atribuida al microambiente tumoral, un estroma desmoplásico compuesto por fibroblastos asociados al cáncer y linfocitos infiltrantes de tumor. El objetivo del estudio fue evaluar el valor pronóstico de los linfocitos infiltrantes de tumor y de los fibroblastos asociados al cáncer en el cáncer de cuerpo y cola de páncreas. MÉTODOS: Utilizando microarray para el análisis de muestras de tejido obtenidas tras la resección de cáncer de páncreas del lado izquierdo, se realizó inmunohistoquímica de linfocitos infiltrantes de tumor (CD45, CD3, CD4, FoxP3 y CD8), fibroblastos asociados al cáncer (vimentina y actina del músculo liso alfa (αSMA)) y marcadores funcionales (PD-L1 y Ki67), y se investigó la asociación con la supervivencia libre de enfermedad y la supervivencia global. Los resultados se obtuvieron tras un análisis cuantitativo asistido por ordenador. Los pacientes se clasificaron en dos grupos, de bajo y alto riesgo, utilizando el valor del percentil 75 como punto de corte.Se incluyeron 43 pacientes en el estudio. En esta población, la mediana de supervivencia libre de enfermedad y de supervivencia global fueron 9 meses y 27 meses, respectivamente. Una alta proporción de linfocitos CD4/CD3 se asoció a peor supervivencia libre de enfermedad (8 meses versus 11 meses; cociente de riesgos instantáneos, hazard ratio, HR 2,2; i.c. del 95% 1,0-4,6; P = 0,041) y supervivencia global (13 meses versus 27 meses; HR 2,6; i.c. del 95% 1,1-5,9; P = 0.028). Una baja proporción αSMA/vimentina junto con una alta proporción CD4/CD3 se correlacionó con peores resultados. No se encontró asociación significativa entre Ki67, PD-L1 y la supervivencia. CONCLUSIÓN: En pacientes con cáncer de páncreas izquierdo resecado, un microambiente tumoral caracterizado por una alta proporción de linfocitos CD4/CD3 junto con una baja proporción de αSMA/vimentina se correlaciona con una peor supervivencia.

We report the case of a 56-year-old woman with pancreatic adenocarcinoma (PA) discovered during an episode of febrile jaundice. A computed tomography (CT) scan showed a mass in the head of the pancreas with circumferential infiltration of the superior mesenteric vein (SMV) and dilatation of the biliary and pancreatic ducts without metastases. The patient benefited from neoadjuvant chemotherapy (FOLFIRINOX) followed by radio-chemotherapy (45 Gy) and chemotherapy (LV5FU2). The revaluation CT revealed SMV thrombosis without portal vein (PV) thrombosis. There was no contact of the tumor with the PV. Pancreatoduodenectomy with combined resection of the SMV was performed with no reconstruction of this venous axis after confirmation of adequate PV, splenic, and left gastric venous flow and the absence of bowel ischemia. The pathological diagnosis was pT4N1R0 PA. There were no bowel angina issues during the follow-up period. At 15 mo after surgery, the patient died of metastatic recurrence.

Background and Aims Fistulas after sleeve gastrectomy are major adverse events of bariatric surgery. The endoscopic management strategy evolved from closure to internal drainage after 2013. The main objective of our study was to evaluate and compare these different approaches. Methods This retrospective study included all patients treated for fistulas after sleeve gastrectomy in a referral center. Closure management was defined as initial treatment that used a covered metal stent and/or endoclips. Internal drainage management was defined as initial treatment by nasocystic drain and/or a double-pigtail stent. Results A total of 100 patients (women N = 78, mean [± standard deviation {SD}] age 42 ± 12 years) were included between 2007 and 2015. The mean (± SD) delay between sleeve gastrectomy and the first endoscopy was 82 ± 125 days. The overall success of endoscopic treatment was 86% within 6 ± 27 months. Two patients died. The primary success of internal drainage and closure management occurred in 19 of 22 (86%) and 49 of 77 (63%) patients, respectively. Among patients in failure for closure management, 22 had secondary internal drainage (18 being successful). Success of initial management was significantly higher for internal drainage ( P = .043). Factors associated with failure of closure management were in multivariable analysis: collection >5 cm ( P = .013). Factors associated with a time >6 months for achieving leakage closure were in multivariable analysis: reoperation before endoscopy ( P = .044) and purulent flow at endoscopy ( P = .043). Conclusions Endoscopic management of fistulas after sleeve gastrectomy was successful in 86% of cases. In cases of collections >5 cm, internal drainage should be proposed first. Surgical reintervention before endoscopy delays treatment success.

Introduction et objectifs L’hemorragie post-pancreatectomie (HPP) tardive est toujours actuellement une des complications les plus redoutees apres chirurgie pancreatique. Sa prise en charge est de nos jours dominee par les traitements endovasculaires percutanes (TEP). Notre objectif principal etait de determiner des facteurs predictifs d’HPP tardive. Notre objectif secondaire etait d’identifier des facteurs de risque d’echec du TEP. Methodes Trois cent sept patients ont beneficie d’une resection pancreatique entre 2013 et 2019. Les patients etaient divises en 2 cohortes : une analyse retrospective a ete conduite sur la periode 1 pour mettre en evidence des facteurs predictifs d’HPP tardive. Puis, nous avons elabore un score predictif d’HPP tardive et l’avons valide de facon prospective sur la periode 2. Resultats Pendant la periode 1, 87,5 % (n = 21) des patients du groupe HPP tardive ont presente une fistule pancreatique postoperatoire (FPPO) et l’analyse multivariee a montre que le sexe masculin (p = 0,044) et les abces intra-abdominaux (p = 0,009) etaient des facteurs predictifs independants d’HPP tardive. Pendant la periode 2, le score elabore etait fiable en ce qui concerne la prediction d’HPP tardive (aire sous la courbe [AUC] 0,78 ; indice de confiance a 95 % [0,69–0,85] ; p Conclusion Le sexe masculin, les abces intra-abdominaux et la FPPO sont des facteurs predictifs independants d’HPP tardive. Un IMC eleve est correle a l’echec du TEP.

To reduce the morbidity and mortality risk for the donor in living donor liver transplantation (LDLT), we previously identified 20% left portal vein (LPV) stenosis as an effective preconditioning method to induce cell proliferation in the contralateral lobe without downstream ipsilateral atrophy. In this study, we report the pathways involved in the first hours after preconditioning and investigate the changes in liver volume and function. Fourteen pigs were used this study. Five pigs were used to study the genetic, cellular and molecular mechanisms set up in the early hours following the establishment of our preconditioning. The remaining nine pigs were equally divided into three groups: sham-operated animals, 20% LPV stenosis, and 100% LPV stenosis. Volumetric scanning and 99 mTc-Mebrofenin hepatobiliary scintigraphy were performed before preconditioning and 14 days after to study morphological and functional changes in the liver. We demonstrated that liver regeneration triggered by 20% LPV stenosis in the contralateral lobe involves TNF-α, IL-6, and inducible nitric oxide synthase 2 by means of STAT3 and hepatocyte growth factor. We confirmed that our preconditioning was responsible for an increase in the total liver volume. Finally, we demonstrated that this volumetric gain was associated with an increase in hepatic functional capacity. NEW & NOTEWORTHY We describe a new preconditioning method for major hepatectomy that is applicable to hepatectomy for donation. We identified 20% left portal vein stenosis as effective preconditioning that is capable of inducing cell proliferation in the contralateral lobe without the downstream ipsilateral atrophy. In this study, we report the pathways involved in the first hours following preconditioning, and we confirm that 20% left portal vein stenosis is responsible for an increase in the functional capacity and total liver volume in a porcine model.

Postoperative pancreatic fistula and pancreas-specific complications have a significant influence on patient management and outcomes after pancreatoduodenectomy. The aim of the study was to assess the value of serum C-reactive protein on the postoperative day 1 as early predictor of pancreatic fistula and pancreas-specific complications. Between 2013 and 2016, 110 patients underwent pancreaticoduodenectomy. Clinical, biological, intraoperative, and pathological characteristics were prospectively recorded. Pancreatic fistula was graded according to the International Study Group on Pancreatic Fistula classification. A composite endpoint was defined as pancreas-specific complications including pancreatic fistula, intra-abdominal abscess, postoperative hemorrhage, and bile leak. The diagnostic accuracy of serum C-reactive protein on postoperative day 1 in predicting adverse postoperative outcomes was assessed by ROC curve analysis. Six patients (5%) died and 87 (79%) experienced postoperative complications (pancreatic-specific complications: n = 58 (53%); pancreatic fistula: n = 48 (44%)). A soft pancreatic gland texture, a main pancreatic duct diameter

Background and study aims Management of post-sleeve gastrectomy fistulas (PSGF) recently has evolved, resulting in prioritization of internal endoscopic drainage (IED). We report our experience with the technique in a tertiary center. Patients and methods This was a single-center, retrospective study of 44 patients whose PSGF was managed with IED, comparing two periods: after 2013 (Group 1; n = 22) when IED was used in first line and before 2013 (Group 2; n = 22) when IED was applied in second line. Demographic data, pre-endoscopic management, characteristics of fistulas, therapeutic modalities and outcomes were recorded and compared between the two groups. The primary endpoint was IED efficacy; the secondary endpoint was a comparison of outcomes depending on the timing of IED in the management strategy. Results The groups were matched in gender (16 female, 16 male), mean age (43 years old), severity of fistula, delay before treatment, and exposure to previous endoscopic or surgical treatments. The overall efficacy rate was 84 % (37/44): 86 % in Group 1 and 82 % in Group 2 (NS). There was one death and one patient who underwent surgery. The median time to healing was 226 ± 750 days (Group 1) vs. 305 ± 300 days (Group 2) (NS), with a median number of endoscopies of 3 ± 6 vs. 4.5 ± 2.4 (NS). There were no differences in number of nasocavity drains and double pigtail stents (DPS), but significantly more metallic stents, complications, and secondary strictures were seen in Group 2. Conclusion IED for management of PSGF is effective in more than 80 % of cases whenever it is used during the therapeutic strategy. This approach should be favored when possible.

In patients undergoing pancreaticoduodenectomy (PD), unrecognized hemodynamically significant celiac axis (CA) stenosis impairs hepatic arterial flow by suppressing the collateral pathways supplying arterial flow from the superior mesenteric artery and leads to serious hepatobiliary complications due to liver and biliary ischemia, with a high rate of mortality. CA stenosis is usually due to an extrinsic compression by a previously asymptomatic median arcuate ligament (MAL). MAL is diagnosed by computerized tomography in about 10% of the candidates for PD, but only half are found to be hemodynamically significant during the gastroduodenal artery clamping test with Doppler assessment, which is mandatory before any resection. MAL release is usually efficient to restore an adequate liver blood inflow and prevent ischemic complications. In cases of failure in MAL release, postponed PD with secondary stenting of the CA and reoperation for PD should be considered as an alternative to immediate hepatic artery reconstruction, which involves the risk of postoperative thrombosis of the arterial reconstruction. We recently used this two-stage strategy in a patient undergoing surgery for pancreatic adenocarcinoma.

Introduction et but de l’etude Analyse d’un groupe de patients opere d’une chirurgie colorectale pris en charge par un logiciel d’aide a la prescription nutritionnelle comparativement a un groupe de patients consecutifs operes d’une chirurgie colorectale et pris en charge de maniere conventionnelle. Materiel et methodes Au total, 485 patients ont beneficie entre janvier 2000 et janvier 2013 d’une exerese colorectale pour cancer colorectal (74,2 % n = 360), pour pathologies benignes (11,5 % ; n = 56) et pathologie inflammatoire (14,2 % ; n = 69). Les resultats (mortalite, morbidite selon la classification de Clavien [CC], duree du sejour hospitalier) d’un groupe de patients ayant beneficie d’un logiciel d’aide a la prise en charge nutritionnelle (GL), ont ete compares a ceux d’une serie anterieure, groupe temoin, (GC) pris en charge conventionnellement. L’analyse statistique a ete faite a l’aide du test du Chi2 et du test de Student. Resultats et analyse statistique Il y avait 59,6 % d’homme et l’âge median de la population etait de 68,2 ans (19–95 ans), sans difference entre les deux groupes (GL : 68,6 contre GC :67,9 ans ; NS). Il n’y avait aucune difference concernant le type de pathologie entre les deux groupes. En revanche, il y avait plus de proctectomie dans le groupe GL contre GC (23,5 % contre 19,9 % p = 0,051). Il y avait significativement plus de patients denutris dans le groupe GL (GL 63,8 % contre GC 45,2 % p

Thèse présentée sous la forme d'une "Thèse Article"; Introduction et objectifs : l’hémorragie post-pancréatectomie (HPP) tardive est toujours actuellement une des complications les plus redoutées après chirurgie pancréatique. Sa prise en charge est de nos jours dominée par les traitements endovasculaires percutanés (TEP).Notre objectif principal était de déterminer des facteurs prédictifs d’HPP tardive. Notre objectif secondaire était d’identifier des facteurs de risque d’échec du TEP.Méthodes : 307 patients ont bénéficié d’une résection pancréatique entre 2013 et 2019. Les patients étaient divisés en 2 cohortes : Une analyse rétrospective a été conduite sur la période 1 pour mettre en évidence des facteurs prédictifs d’HPP tardive. Puis, nous avons élaboré un score prédictif d’HPP tardive et l’avons validé de façon prospective sur la période 2.Résultats : pendant la période 1, 87.5% (n=21) des patients du groupe HPP tardive ont présenté une fistule pancréatique post-opératoire (FPPO) et l’analyse multivariée a montré que le sexe masculin (p=0.044) et les abcès intra-abdominaux (p=0.009) étaient des facteurs prédictifs indépendants d’HPP tardive. Pendant la période 2, le score élaboré était fiable en ce qui concerne la prédiction d’HPP tardive (aire sous la courbe (AUC) 0.78; indice de confiance à 95% [0.69-0.85] ; p