Anévrisme de l’artère splénique rompu dans l’estomac: traitement chirurgical après échec d’une tentative d’embolisation

L'anévrisme de l'artère splénique (AAS) est une entité pathologique rare le plus souvent asymptomatique. Nous rapportons le cas d'un patient âgéde 60 ans, hypertendu qui s'est présenté aux urgences pour un épisode d'hématémèse sans retentissement hémodynamique. Un bilan completcomportant un Angioscanner abdominal a mis en évidence un anévrisme de l'artère splénique refoulant la paroi postérieure de l'estomac en avant.Le diagnostic d'anévrisme de l'artère splénique rompu dans l'estomac a été posé et un traitement endovasculaire à type d'embolisation par coilseffectué. Au 5ème jour post embolisation, le patient nous a été référé pour une persistance de mélénas. Un traitement chirurgical a été décidé. Lamise à plat de l'anévrisme a permis d'évacuer les coils et le thrombus. L'objectif de cette observation est de montrer que l'embolisation d'un AASrompu dans l'estomac a été une cause de retard thérapeutique qui pourrait être fatal pour le patient. Le traitement de référence est la cure chirurgicale de l'AAS par voie conventionnelle sans rétablissement de la continuité  artérielle splénique, sans splénectomie et avec suture de l'orifice digestif

Current Opinion and Practice on Peritoneal Carcinomatosis Management: The North African Perspective.

The status of peritoneal surface malignancy (PSM) management in North Africa is undetermined. The aim of this study was to assess and compare current practice and knowledge regarding PSM and examine satisfaction with available treatment options and need for alternative therapies in North Africa. This is a qualitative study involving specialists participating in PSM management in North Africa. The survey analyzed demographic characteristics and current knowledge and opinions regarding PSM management in different institutions. We also looked at goals and priorities, satisfaction with treatment modalities and heated intraperitoneal chemotherapy (HIPEC) usefulness according to specialty, country, years of experience, and activity sector. One-hundred and three participants responded to the survey (response rate of 57%), including oncologists and surgeons. 59.2% of respondents had more than 10 years experience and 45.6% treated 20-50 PSM cases annually. Participants satisfaction with PSM treatment modalities was mild for gastric cancer (3/10 [IQR 2-3]) and moderate for colorectal (5/10 [IQR 3-5]), ovarian (5/10 [IQR 3-5]), and pseudomyxoma peritonei (5/10 [IQR 3-5]) type of malignancies. Good quality of life and symptom relief were rated as main priorities for treatment and the need for new treatment modalities was rated 9/10 [IQR 8-9]. The perceived usefulness of systemic chemotherapy in first intention was described as high by 42.7 and 39.8% of respondents for PSM of colorectal and gastric origins, while HIPEC was described as highly useful for ovarian (49.5%) and PMP (73.8) malignancies. The management of PSM in the North African region has distinct differences in knowledge, treatments availability and priorities. Disparities are also noted according to specialty, country, years of expertise, and activity sector. The creation of referral structures and PSM networks could be a step forward to standardized PSM management in the region

LE TRAITEMENT CHIRURGICAL DE L’ ANGIODYSPLASIE DUODENALE SURGICAL TREATEMENT OF DUODENAL ANGIODYSPLASIA

Management of angiodysplasia is usually based on endoscopic therapies. Surgical treatement is required in massive bleeding and when the others procedures failed. However the duodenal seat and diffuse lesions remains a challenging problem. We present two patients with duodenal angiodysplasia who underwent cephalic duodenopancreatectomy. Both patients had good follow-up. We justify our choice which is unusual by the duodenal seat, diffuse and symptomatic lesions and recurrent hemorrhage.Le traitement de l’angiodysplasie fait   habituellement appel aux méthodes endoscopiques. Le recours à la chirurgie s’impose devant une hémorragie massive ou en cas d’échec des autres thérapeutiques .Toutefois le siège duodénal et le caractère diffus des lésions angiodysplasiques rendent difficile la décision thérapeutique. Nous présentons deux cas d’angiodysplasie duodénale traités chirurgicalement. Le geste a consisté en une duodénopancréatectomie céphalique .Les suites immédiates et à distance étaient simples. Nous justifions notre choix thérapeutique qui reste exceptionnel par le siège duodénal des lésions, leur caractère symptomatique et durable ainsi que leur nombre élevé

LYMPHOME NON HODGKINIEN PRIMITIF DU FOIE : A PROPOS D’UN CAS ET REVUE DE LA LITTERATURE

The invasion secondary liver is common during the evolution of systemic lymphoma, primary lymphoma of the liver are very rare estimated at 1% of all extranodal lymphomas. We report a patient of 37 years, without previous medical history especially, who consulted for isolated pain in the right hypochondrium lasting for five months in a conservation context of general condition, abdominal ultrasound revealed a mass of malignant appearance of the left liver, confirmed by an abdominal CT scan. A liver biopsy was performed, showing the histology associated with immunohistochemistry; non-Hodgkin lymphoma, diffuse large B cells expressing CD20, the rest of the staging did not reveal any other location, including not of lymph node involvement. The patient received chemotherapy: RCHOP: rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone, eight treatments, with good clinical and radiological response and good tolerance, with a decline in 4 months.L’envahissement secondaire du foie est fréquent au cours de l’évolution des lymphomes systémiques. Les lymphomes primitifs du foie sont très rares estimés à 1% de tous les lymphomes extraganglionnaire [1,2]. Nous rapportons l’observation d’une patiente de 37 ans, sans antécédents pathologiques particuliers, qui a consulté pour des douleurs isolées de l’hypochondre droit, évoluant depuis 5 mois dans un contexte de conservation de l’état général, l’échographie abdominale et la tomodensitométrie abdominale ont révélé ; une masse du foie gauche d’allure maligne. Une biopsie du foie a été réalisée, montrant à l’étude histologique associée à l’immunohistochimie ; un lymphome non hodgkinien type B diffus à grandes cellules exprimant CD20, le reste du bilan d’extension n’a révélé aucune autre localisation, notamment pas d’atteinte ganglionnaire. La patiente a reçu une chimiothérapie de type RCHOP : rituximab, cyclophosphamide, doxorubicine, vincristine et prednisone, huit cures, avec une bonne réponse clinique et radiologique et une bonne tolérance, avec un recule de 4 mois

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Elective cancer surgery in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic: An international, multicenter, comparative cohort study

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study.

PURPOSE: As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS: This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS: Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION: Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Global wealth disparities drive adherence to COVID-safe pathways in head and neck cancer surgery

Peer reviewe

The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study

AIM: The SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery. METHODS: This was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January-April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin. RESULTS: Overall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P < 0.001). After adjustment, delay was not associated with a lower rate of complete resection (OR 1.18, 95% CI 0.90-1.55, P = 0.224), which was consistent in elective patients only (OR 0.94, 95% CI 0.69-1.27, P = 0.672). Longer delays were not associated with poorer outcomes. CONCLUSION: One in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID-19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long-term survival attributable to delays is likely to be due to micro-metastatic disease