“Fibrous nests” in human hepatocellular carcinoma express a Wnt-induced gene signature associated with poor clinical outcome

International audienc

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Identification of intestinal phenotypes correlated with neuro-behavioural patterns in obese minipigs undergoing Roux-en-Y gastric bypass

La dérivation gastrique de type Roux-en-Y (RYGBP) est une des interventions de référence dans la prise en charge médico-chirurgicale de l’obésité. Ses mécanismes ne sont pas encore tous élucidés et son impact spécifique sur le contrôle du comportement alimentaire reste à approfondir. L’objectif de cette thèse était la mise au point d’un modèle de RYGBP chez le miniporc Yucatan obèse puis la réalisation d’une étude transversale intégrative des effets spécifiques du RYGBP sur l’axe microbiote-intestin-cerveau. Nous avons émis l’hypothèse que le RYGBP induirait des modifications de cet axe et que les réponses cérébrales à la stimulation sucrée en imageries fonctionnelles dans les zones impliquées dans le comportement alimentaire lui seraient liées. Nous avons montré que la perte de poids induite par le RYGBP ou une chirurgie SHAM modulait différemment les réponses frontostriatales lors d’une stimulation sucrée orale témoignant d’un traitement hédonique et d’un contrôle inhibiteur différents. L'expression des gènes cérébraux impliqués dans les systèmes sérotoninergiques et cannabinoïdes a été affectée par le RYGBP. Le microbiote cæcal ainsi que le métabolome plasmatique ont été profondément modifiés par le RYGBP. L'intégration des données avec une analyse WGCNA a permis d'identifier de fortes interactions entre certaines familles de bactéries et métabolites liés pour certaines spécifiquement au RYGBP et pour d’autres aux réponses cérébrales en IRM fonctionnelle. Notre modèle représente une belle opportunité d'améliorer, par des analyses intégratives et systémiques, nos connaissances sur les changements neurocognitifs et métaboliques complexes induits par le RYGBP. Des analyses et études supplémentaires sont nécessaires pour explorer la dynamique de ces adaptations dans le temps, au décours de l’intervention et à long terme.RYGBP is one of the gold standard for surgical management of obesity. All mechanisms engaged are not yet fully understood and its specific impact on the control of eating behaviour remains to be further investigated. The objective of this thesis was to develop a model of RYGBP in the obese Yucatan minipig and to conduct an integrative cross-sectional study of the specific effects of RYGBP on the gut-brain axis. We hypothesized that RYGBP would induce changes in this axis and that brain responses to Sucrose stimulation in functional imaging in areas involved in eating behaviour would be linked to it. We have shown that weight loss induced by RYGBP or SHAM surgery modulates frontostriatal responses differently to oral Sucrose stimulation, indicating different hedonic processing and increased inhibitory control. The expression of brain genes (serotonergic and cannabinoid systems) was affected by RYGBP. The cecal microbiota as well as the plasma metabolites were impacted by RYGBP. Integration with the WGCNA analysis identified strong interactions between OTU and metabolites and some of which were specifically linked to RYGBP or to functional MRI results. Our model represents an opportunity to improve through integrative and systemic analyses, the knowledge of the complex neurocognitive and metabolic changes induced by RYGBP. Further analysis and studies are needed to explore the dynamics of these adaptations at short and long term after surgery

Systematic Nasogastric Tube Decompression Following Pancreaticoduodenectomy-Is it Safe?-Reply

International audienc

Data sharing practices in the surgical field

Protoco

Complications nutritionnelles de la chirurgie de l’obésité : prévalence, prévention, traitement. Revue systématique de littérature

International audienceBackgroundIn France, the use of obesity surgery is increasing sharply. Yet effective on severe obesity and its comorbidities, it exposes to the risk of serious postoperative complications, including nutritional issues. We aimed to synthesize the research-based evidence concerning these nutritional complications: prevalence, risk factors, recommendations on their treatment and prevention.MethodsWe carried out a PRISMA systematic review, the articles included were analyzed into a synoptic table, allowing the development of summary tables.ResultsPostoperative nutritional deficiencies are frequent (vitamin D 25-100%, B12 7-70%, iron 7-63%). A lifelong micronutrient supplementation is essential (multivitamin and minerals, vitamin D-calcium, iron, vitamin B12) to prevent the hematological, neurological, or musculoskeletal consequences of deficiencies. Their prevention-screening-treatment are part of a global postoperative management which must be multimodal and interdisciplinary. Severe malnutrition exists (<5%) and could lead to serious complications ("nutritional disasters") that may require artificial nutrition. Studies with high level of evidence on postoperative follow-up and supplementation are rare, not allowing the development of consensus guidelines. To prevent nutritional deficiencies and their consequences, the collaboration between general practitioners and medico-surgical teams should be strengthened.ConclusionNutritional complications are common after obesity surgery. Potentially serious, they are accessible to screening and prevention, through lifelong biochemical and clinical monitoring, and micronutrient supplementation. A coordinated follow-up, as part of a tailored "community care-hospital" patient healthcare pathway, could improve postoperative outcomes.Contexte Bien qu’indiquée pour améliorer les comorbidités de l’obésité, la chirurgie de l’obésité, en forte augmentation, expose au risque de complications postopératoires, notamment nutritionnelles. Notre objectif a été de synthétiser les données de la littérature concernant ces complications nutritionnelles :prévalence, facteurs de risque, recommandations sur leurs traitement et prévention.MéthodeNous avons conduit cette revue systématique de la littérature selon la méthode PRISMA, les articles inclus ont été analysés en tableau synoptique, permettant l’élaboration de tableaux de synthèse.RésultatsLes déficits nutritionnels sont fréquents après chirurgie de l’obésité (vitamine D25–100 %, B12 7–70 %, fer 7–63 %), imposant une supplémentation en micronutriments (complexes multivitamines-minéraux, vitamine D-calcium, fer, B12), pour en prévenir les conséquences hématologiques, neurologiques ou musculosquelettiques. Leurs prévention-dépistage-correction s’intègrent dans une prise en charge multimodale et interdisciplinaire. Les dénutritions sévères ou « catastrophes nutritionnelles » existent (<5 %) et peuvent nécessiter une nutrition artificielle. Les études de haut niveau de preuve sur les modalités de suivi et de supplémentations sont rares, ne permettant pas l’élaboration de recommandations consensuelles. Pour prévenir les déficits nutritionnels et leurs conséquences, la collaboration entre le médecin traitant et l’équipe médicochirurgicale doit se renforcer.ConclusionLes complications nutritionnelles de la chirurgie de l’obésité sont fréquentes, potentiellement graves, accessibles au dépistage et à la prévention, au moyen d’un suivi bioclinique et d’une supplémentation en micronutriments à vie. Un suivi coordonné, intégré dans un parcours de soins« ville-hôpital », pourrait optimiser les résultats postopératoires

Modified Appleby Procedure, Distal Splenopancreatectomy with Celiac Axis Resection

International audienceBACKGROUND: Modified Appleby procedure could be indicated in stage III locally advanced body pancreatic ductal adenocarcinoma (PDAC) involving the celiac axis after neoadjuvant treatment. PATIENTS AND METHODS: We report the case of a 38-year-old woman presenting a tumor arising from the body of the pancreas, involving the celiac trunk with the common hepatic artery and having contact with the anterior surface of the superior mesenteric artery. A fine-needle aspirate biopsy confirmed the diagnosis of PADC. Eight cycles of FOLFIRINOX followed by chemoradiotherapy (50.4 Gy) were conducted. After 6 months, the CA19-9 levels were normalized, and the tumor remained stable without local growth or distant metastasis. To reduce the risk of ischemia-related complications and develop the pancreaticoduodenal arcades, a preoperative embolization of the common hepatic artery was performed. Then, surgical resection was considered 4 weeks after embolization. RESULTS: The patient underwent a modified Appleby procedure including distal splenopancreatectomy with en bloc celiac axis resection combined with lateral portal vein resection. Venous reconstruction was carried out using peritoneal patch.1 Pathologic evaluation revealed a 2.5-cm PDAC with negative resection margins. Postoperative course was marked by acute ischemic cholecystitis requiring reoperation at postoperative day 3. The treatment was completed with four cycles of FOLFIRINOX, and she was free of disease 6 months after surgery. CONCLUSIONS: Nowadays, modified Appleby procedure is more frequently performed due to improvements in responses to chemotherapy and radiotherapy which have led to better local control and more aggressive approaches in highly selected patients

In Response to "The Outcome of Bariatric Surgery in Patients Aged 75 Years and Older"

International audienc