Gallbladder carcinoma fortuitously discovered on specimen after cholecystectomy: should re-operation be advocated?

Le cancer de la vésicule biliaire est rare, de pronostic sévère et souvent diagnostiqué de manière fortuite sur pièce de cholécystectomie. La survie des cancers découverts fortuitement est cependant meilleure que lorsque le diagnostic est fait en pré-opératoire, car il s’agit le plus souvent de « petits cancers ». Le compte-rendu opératoire détaillé, l’analyse complète du compte-rendu anatomo-pathologique de la pièce de cholécystectomie, complétés d’un bilan d’extension, permettent de classer la lésion selon le stade TNM qui sera déterminant pour décider de la prise en charge ultérieure et notamment de l’indication d’une réintervention chirurgicale carcinologique. Seuls les adénocarcinomes n’envahissant pas la musculeuse (T1a) et avec des marges de résections chirurgicales saines peuvent être considérés comme ayant eu une résection satisfaisante. Toutes les autres lésions nécessiteront une réintervention comportant une résection hépatique, un curage ganglionnaire, une recoupe du canal cystique (plus ou moins associée à une résection de la voie biliaire principale) ainsi qu’une exérèse des orifices de trocarts lorsque la cholécystectomie avait été réalisée par laparoscopie. La réintervention ne doit laisser aucun résidu tumoral si l’on veut espérer un bénéfice en termes de survie pour le patient.Cancer of the gallbladder cancer is rare and associated with a poor prognosis. It is frequently fortuitously discovered on a specimen after cholecystectomy. Survival with such cancers fortuitously discovered is often better than when diagnosed pre-operatively, as they are often of small size.A detailed operative report, the whole analysis of the pathological report of the surgical specimen, followed with a staging of the lesion according to the TNM classification will be of utmost importance to decide of the further management and especially if surgical re-operation is indicated. Resection can be considered as satisfactory only if the adenocarcinoma is not invading the musculosa (T1a) and shows safe resection margins. All other lesions should be re-operated with hepatic resection, lymphnode dissection, resection of the cystic duct (more or less associated to the resection of the main biliary tract) as well as the exeresis of the trocar orifices if cholecystectomy has been performed by laparoscopy. Surgical re-operation should not leave any tumoral residue if a benefit in terms of survival is expected for the patient

Open versus laparoscopically-assisted oesophagectomy for cancer: a multicentre randomised controlled phase III trial - the MIRO trial

<p>Abstract</p> <p>Background</p> <p>Open transthoracic oesophagectomy is the standard treatment for infracarinal resectable oesophageal carcinomas, although it is associated with high mortality and morbidity rates of 2 to 10% and 30 to 50%, respectively, for both the abdominal and thoracic approaches. The worldwide popularity of laparoscopic techniques is based on promising results, including lower postoperative morbidity rates, which are related to the reduced postoperative trauma. We hypothesise that the laparoscopic abdominal approach (laparoscopic gastric mobilisation) in oesophageal cancer surgery will decrease the major postoperative complication rate due to the reduced surgical trauma.</p> <p>Methods/Design</p> <p>The MIRO trial is an open, controlled, prospective, randomised multicentre phase III trial. Patients in study arm A will receive laparoscopic-assisted oesophagectomy, i.e., a transthoracic oesophagectomy with two-field lymphadenectomy and laparoscopic gastric mobilisation. Patients in study arm B will receive the same procedure, but with the conventional open abdominal approach. The primary objective of the study is to evaluate the major postoperative 30-day morbidity. Secondary objectives are to assess the overall 30-day morbidity, 30-day mortality, 30-day pulmonary morbidity, disease-free survival, overall survival as well as quality of life and to perform medico-economic analysis. A total of 200 patients will be enrolled, and two safety analyses will be performed using 25 and 50 patients included in arm A.</p> <p>Discussion</p> <p>Postoperative morbidity remains high after oesophageal cancer surgery, especially due to major pulmonary complications, which are responsible for 50% of the postoperative deaths. This study represents the first randomised controlled phase III trial to evaluate the benefits of the minimally invasive approach with respect to the postoperative course and oncological outcomes in oesophageal cancer surgery.</p> <p>Trial Registration</p> <p><a href="http://www.clinicaltrials.gov/ct2/show/NCT00937456">NCT00937456</a> (ClinicalTrials.gov)</p

Innervation of the pelvis and perineum : anatomical and immunohistochemical study and three-dimensional reconstruction in the fœtus and female adult. Surgical applications during protectcomy for cancer

Introduction : Le système nerveux autonome (SNA) est en situation supralévatorienne, le système somatique en situation infra lévatorienne. Le sympathique assurerait les fonctions de sécrétion et le parasympahtique, les fonctions dʼérection. Le rectum est en rapport étroit avec ces éléments nerveux. La protectomie avec exérèse totale du mésorectum pour cancer est associée à des séquelles sexuelles par lésion iatrogène des nerfs pelviens.Objectifs : Étudier la physiologie et lʼanatomie topographique et structurelle de l'innervation pelvipérinéale Matériels et méthodes : Cinq pelvis de foetus et dix pelvis dʼadultes féminins ont été prélevés pour études macroscopiques, microscopiques etimmunohistochimiques des nerfs pelviens. Les coupes ont été colorées puis immunomarquées pour détecter les fibres nerveuses (PS-100), somatiques(PMP22), autonomes adrénergiques (TH), cholinergiques (VAChT), sensitives(CGRP) et les fibres pro-érectiles (nNOS). Les lames ont été numérisées et reconstruites en 3D.Résultats : Les fibres nerveuses du SNA, richement interconnectées,véhiculent de façon mixte lʼinflux sympathique et parasympathique.Celles issues du plexus hypogastrique inférieur contrôlant les fonctions sexuelles sont regroupées avec le pédicule vaginal long et forment la bandelette neuro-vasculaire (BNV) sur la face antérolatérale du rectum à « 2et 10h ». Cette BNV est en avant de lʼexpansion postérolatérale du septum recto vaginal (SRV) qui la protège et qui est lʼéquivalent chez lʼhomme du fascia de Denonvilliers. Cette BNV concentre lʼensemble des fibres nerveusespro-érectiles destinées au périnée. Une lésion tronculaire de cette bandelette pourrait conduire à un trouble de lʼérection clitoridienne et de la lubrification vulvaire car, à ce niveau, les efférences sympathiques et parasympathiques coexistent.Conclusion: Un modèle anatomo-physiologique et pédagogiquedʼinnervation pelvipérinéale féminine a été développé. Ces travaux offrent des perspectives dʼétudes cliniques afin de mieux évaluer les dysfonctions sexuelles postopératoires.Introduction: The nerve supply of the autonomic nervous system (ANS) to the pelvis is located above the levator ani muscle, and the somatic nerve supply to the pelvis is situated below levator ani. Sympathetic innervation assures secretory functions and parasympathetic innervation allows erection. The rectum is anatomically closely associated with these nerves. Protectomy with total excision of the mesorectum for cancer is associated with sexual sequellae due to iatrogenic damage to the pelvic nerves.Objectives: To study the physiology and topographic and structural anatomy of the innervation of the pelvis.Materials and methods: Five fœtal pelvises and ten adult female pelvises were collected for macroscopic, microscopic, and immunohistochemical studies of pelvic nerves. Sections were stained and then immunostained to reveal nerve fibres (PS-100), somatic nerves (PMP22), adrenergic autonomic nerves (TH), cholinergic autonomic nerves (VAChT), sensory nerves (CGRP) and pro-erectile nerves (nNOS). Sections were numbered and reconstructed in 3D.Results: ANS nerve fibres, densely interconnected, carry a combination of sympathetic and parasympathetic fibres.Nerve fibres controlling sexual function from the inferior hypogastric plexus are clustered along the vaginal pedicle and form the neurovascular bundle (NVB) on the anterolateral face of the rectum between “2 and 10 o’clock”. This NVB is in front of the expansion of the rectovaginal septum (RVS) which protects it. In males, the equivalent structure is the rectoprostratic fascia. This NVB contains all of the pro-erectile nerves supplying the perineum. A truncal lesion to this bundle could result in erectile dysfunction of the clitoris as well as difficulties in vulvar lubrication because sympathetic and parasympathetic efferent fibres are both present at this site.Conclusion: An educational anatomical and physiological model of the innervation of the female pelvis and perineum has been developed. This work offers perspectives for clinical studies to facilitate better evaluation of cases of post-operative sexual dysfunction

Inguinal lymph node dissection

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Side-to-side choledochoduodenostomy for common bile duct stones

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Safeness of Simultaneous Colonic Resection and Hepatic Radiofrequency Ablation

International audienceBackground and Objectives:Previous reports showed an increased risk of infectious complications when liver radiofrequency ablation (RFA) is performed simultaneously to colorectal resection. The aim of this study was to compare early and long-term outcomes of simultaneous versus staged strategy.Methods:Data from colorectal cancer liver metastases consecutively treated by surgery of the primary tumor with an associated liver RFA procedure between January 1, 2010, and January 31, 2020. Patients were divided into two groups: RFA performed during colorectal surgery (simultaneous) or in a different moment (staged). Patients were manually matched (1:1) to minimize the influence of known covariates.Results:Seventy-two patients were included. After matching, there was no difference between the two groups in morbidity or mortality. Hospital stay was 2 days shorter in the simultaneous group.Conclusions:Early or long-term outcomes were identical between the two strategies. The simultaneous strategy was associated with a shorter duration of hospitalization although not significant. Simultaneous colorectal resection and liver RFA are safe and must be included in surgeons’ armamentarium

Incidence and risk factors for Chyle leak after pancreatic surgery for cancer: A comprehensive systematic review

International audienceBackground: Chyle leak (CL) is a clinically relevant complication after pancreatectomy. Its incidence and the associated risk factors are ill defined, and various treatments options have been described. There is no consensus, however, regarding optimal management. The present study aims to systematically review the literature on CL after pancreatectomy. Methods: A systematic review from PubMed, Scopus and Embase database was performed. Studies using a clear definition for CL and published from January 2000 to January 2021 were included. The PRISMA guidelines were followed during all stages of this systematic review. The MINORS score was used to assess methodological quality. Results: Literature search found 361 reports, 99 of which were duplicates. The titles and abstracts of 262 articles were finally screened. The references from the remaining 181 articles were manually assessed. After the exclusions, 43 articles were thoroughly assessed. A total of 23 articles were ultimately included for this review. The number of patients varied from 54 to 3532. Incidence of post pancreatectomy CL varied from 1.3% to 22.1%. Main risk factors were the extent of the surgery and early oral or enteral feeding. CL dried up spontaneously or after conservative management within 14 days in 53% to 100% of the cases. Conclusions: The extent of surgery is the most common predictor of risk of CL. Conservative treatment has been shown to be effective in most cases and can be considered the treatment of choice. We propose a management algorithm based on the current available evidence

Contemporary Outcomes for the Curative Treatment of Colorectal Cancer Pulmonary Metastases

Purpose: Treatment of pulmonary metastases (PM) from colorectal cancer (CRC) is the standard of care by several guidelines from Europe and the USA, but the validity of this strategy has been recently questioned, and the available evidence supporting this strategy is weak. We report the outcomes of a curative intent strategy in a very recent and homogenous series of patients. Methods: We did a retrospective review of all curative intent surgical or ablative treatment of PM from CRC performed consecutively in 3 French institutions from January 2015 to December 2019. Demographics, clinicopathological, and molecular characteristics were evaluated. Cox regression models were used to identify prognostic factors related to local recurrence and disease-free survival. Results: Records from 152 patients were reviewed. One-hundred thirty-five patients (88%) had surgical metastasectomy. Median age was 67&nbsp;years. Most of the patients had a single lesion (66%), and 16% had synchronous PM. Eighty-one patients (53%) experienced recurrence, and the thorax was the most common site of recurrence. Median disease-free survival and overall survival were 35&nbsp;months and 78&nbsp;months after PM treatment. At the end of the study, only 17% of the patients died. Pulmonary tumor burden was correlated with disease-free survival in univariate analysis, but multivariate analysis did not find any prognostic factor independently associated with local recurrence or survival. Conclusion: Our finds corroborate existing recommendation for the invasive treatment of PM from CRC in selected patients

Local immunomodulation combined to radiofrequency ablation results in a complete cure of local and distant colorectal carcinoma

International audienceRadiofrequency ablation (RFA) of colorectal liver metastases activates a specific T-cell response that is ineffective in avoiding recurrence. Recently, local immunomodulation garnered interests as a way to improve the immune response. We were interested in improving the RFA immune response priming to propose a curative treatment of colorectal cancer (CRC) based on antitumor immunity. First, we demonstrated that the RFA did not increase the tumor infiltrating lymphocytes in secondary distant tumors of patients and in mice model and could not avoid relapse. Remarkably, RFA and in situ immunomodulation with GM-CSF-BCG hydrogel induced complete cure of microscopic secondary lesions in mice, related to a strong specific immune response. Then, we demonstrated that the immune escape of large secondary lesions was reversed by addition of the systemic PD-1 blockade to the in situ immunomodulation. The lack of an effective distant immune response in patients treated with RFA confirmed the relevance of this new combination strategy. Increasing the in situ priming response of radiofrequency ablation provides effective adjuvants to induce an abscopal effect. In the case of large lesions, synergy between PD1 blockade inhibitor, ineffective alone or after single RFA, with in situ immunomodulation, could lead to reconsideration of the use of checkpoint inhibition in metastatic MSS CRC