What is the Best Option Between Primary Diverting Stoma or Endoscopic Stent as a Bridge to Surgery with a Curative Intent for Obstructed Left Colon Cancer? Results from a Propensity Score Analysis of the French Surgical Association Multicenter Cohort of 518 Patients

International audienceBackgroundEndoscopic stent (ES) as a bridge to surgery in obstructed left colon cancer (OLCC) is controversial. Our goal was to compare the operative and oncological results of primary diverting colostomy (PDC) and ES for the curative treatment of OLCC.MethodsBetween 2000 and 2015, patients who underwent PDC or ES in a curative intent for OLCC at member centers of the French Surgical Association were included. Patients with unresectable tumors and/or synchronous metastases were excluded. Comparisons between the two groups were performed after ponderation with propensity score for: demographic and tumor characteristics, operative, and oncological results.ResultsA total of 518 patients were included: PDC (n=327); ES (n=191). The demographic characteristics were similar between the groups. ES failed in 23% of the patients (11% perforation). Cumulative tumor resection rates were 80% and 86% after PDC and ES, respectively (p=0.049). The rates of primary anastomosis were 57% in the PDC group and 40% in the ES group (p<0.0001). The permanent stoma rates were similar between the two groups (29% vs. 28%, p=0.0586). Cumulative overall, surgical, and medical complications were significantly higher in PDC group. The resected tumors were significantly smaller and less frequently perforated and metastatic in the PDC group. The median overall survival was significantly higher after PDC (123.6 vs. 58.5months, p=0.046), whereas the median disease-free survival was similar between the two groups (54.1 vs. 53.6months, p=0.646).ConclusionsAlthough endoscopic stenting is associated with better surgical outcomes than diverting stoma, it may negatively impact histological features and overall survival

Safety of inhaled corticosteroids delivered by plastic and metal spacers

Methods: Thirty children (mean 4.3 (SD 0.3) years) received 200 µg budesonide twice daily by NC or AC, both with the mask provided, in a randomised, two month crossover trial. Twenty four hour urinary free cortisol (UFC) was determined as a measure of HPA suppression. Results: UFC decreased from 42.3 (7.8) nmol UFC/nmol creatinine control to 26.2 (2.4) (p = 0.06 v control) after AC, and to 24.5 (2.5) (p = 0.04 v control) after NC (p = 0.4 AC v NC). Conclusions: Despite a greater total dose delivered to the mouth, NC is not associated with greater HPA suppression when using 400 µg/day budesonide under real life conditions in young children

Emergency Surgery for Obstructive Colon Cancer in Elderly Patients

International audienceBACKGROUND: Although elderly patients constitute most of the patients undergoing surgery for obstructed colon cancer, available data in the literature are very limited.OBJECTIVE: The purpose of this study was to assess the management and outcomes of elderly patients treated for obstructed colon cancer.DESIGN: This was a multicenter, retrospective cohort study.SETTINGS: Between 2000 and 2015, 2325 patients managed for an obstructed colon cancer in member centers of the French National Surgical Association were identified. Data were collected by each center on a voluntary basis after institutional approval. Bowel obstruction was defined clinically and confirmed by imaging.PATIENTS: Three age groups were defined, including patients <75 years, 75 to 84 years, and ≥85 years.MAIN OUTCOME MEASURES: Postoperative and oncologic results in elderly patients with an obstructed colon cancer were measured. Relative survival was calculated as the ratio of the overall survival with the survival that would have been expected based on the corresponding general population.INTERVENTIONS: A total of 302 patients (13%) underwent colonic stent insertion, and 1992 (87%) underwent surgery as emergency procedure.RESULTS: A total of 2294 patients were analyzed (<75 y, n = 1200 (52%); 75–84 y, n = 650 (28%); and ≥85 y, n = 444 (20%)). Elderly patients were more likely to be women (p < 0.0001), to have proximal colon cancer (p < 0.0001), and to have a higher incidence of comorbidities (p < 0.0001). The use of colonic stent or the type of surgery was identical regardless of age. In patients with resected colon cancer, elderly patients had less stage IV disease (p < 0.0001). The absence of tumor resection (p < 0.0001) and definitive stoma rate increased with age (p < 0.0001). Postoperative mortality and morbidity were significantly higher in elderly patients (p < 0.0001), but surgical morbidity was similar across age groups (p = 0.60). Postoperative morbidity was correlated to the 6-month mortality rate in elderly (p < 0.0001). Overall and disease-free survivals were significantly lower in more elderly patients (p < 0.0001) but relative survival was not (p = 0.09).LIMITATIONS: It is quite difficult to know how to interpret these data as a whole, given the inherent bias in the study population, lack of ability to stratify by performance status, and long study period duration.CONCLUSIONS: Elderly patients have high morbidity with lower survival in the highest age ranges of elderly subgroups. These data should be considered when deciding on an operative approach. See Video Abstract at http://links.lww.com/DCR/A964

Pancreatic cancer: French clinical practice guidelines for diagnosis, treatment and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, ACHBT, AFC)

Background: This document is a summary of the French intergroup guidelines regarding the management of pancreatic adenocarcinoma (PA), updated in July 2018. Design: This collaborative work was produced under the auspices of all French medical and surgical societies involved in the management of PA. It is based on the previous guidelines, recent literature review and expert opinions. Recommendations were graded in three categories, according to the level of evidence. Results: Over the last seven years, significant changes in PA management have been implemented in clinical practice. Imaging/staging: diffusion magnetic resonance imaging is useful before surgery to rule out small liver metastases. Surgery: centralization of pancreatic surgery in expert centers is associated with a decreased postoperative mortality. Adjuvant chemotherapy: modified FOLFIRINOX in fit patients, or gemcitabine, or 5-FU, or gemcitabine plus capecitabine, to be discussed on a case-by-case basis. Locally advanced PA: no survival benefit of chemoradiotherapy. Metastatic PA: FOLFIRINOX and gemcitabine plus nab-paclitaxel combination are first-line standards in fit patients; second-line with 5FU/nal-IRI or 5FU/oxaliplatin combination after first-line gemcitabine. Conclusion: Guidelines for management of PA are continuously evolving and need to be regularly updated. This constant progress is made possible through clinical and translational research. However, as each individual case is particular, they cannot substitute to multidisciplinary tumor board discussion. (C) 2018 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved

Right-sided vs. left-sided obstructing colonic cancer: results of a multicenter study of the French Surgical Association in 2325 patients and literature review

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Is Adjuvant Chemotherapy Necessary for Obstructing Stage II Colon Cancer? Results From a Propensity Score Analysis of the French Surgical Association Database

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