Outcomes and Risk Score for Distal Pancreatectomy with Celiac Axis Resection (DP-CAR): An International Multicenter Analysis

Background: Distal pancreatectomy with celiac axis resection (DP-CAR) is a treatment option for selected patients with pancreatic cancer involving the celiac axis. A recent multicenter European study reported a 90-day mortality rate of 16%, highlighting the importance of patient selection. The authors constructed a risk score to predict 90-day mortality and assessed oncologic outcomes. Methods: This multicenter retrospective cohort study investigated patients undergoing DP-CAR at 20 European centers from 12 countries (model design 2000–2016) and three very-high-volume international centers in the United States and Japan (model validation 2004–2017). The area under receiver operator curve (AUC) and calibration plots were used for validation of the 90-day mortality risk model. Secondary outcomes included resection margin status, adjuvant therapy, and survival. Results: For 191 DP-CAR patients, the 90-day mortality rate was 5.5% (95 confidence interval [CI], 2.2–11%) at 5 high-volume (≥ 1 DP-CAR/year) and 18% (95 CI, 9–30%) at 18 low-volume DP-CAR centers (P = 0.015). A risk score with age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, multivisceral resection, open versus minimally invasive surgery, and low- versus high-volume center performed well in both the design and validation cohorts (AUC, 0.79 vs 0.74; P = 0.642). For 174 patients with pancreatic ductal adenocarcinoma, the R0 resection rate was 60%, neoadjuvant and adjuvant therapies were applied for respectively 69% and 67% of the patients, and the median overall survival period was 19 months (95 CI, 15–25 months). Conclusions: When performed for selected patients at high-volume centers, DP-CAR is associated with acceptable 90-day mortality and overall survival. The authors propose a 90-day mortality risk score to improve patient selection and outcomes, with DP-CAR volume as the dominant predictor

Le reflux biliaire duodéno-gastrique et gastro-œsophagien

This study reviews current data regarding duodenogastric and gastroesophageal bile reflux-pathophysiology, clinical presentation, methods of diagnosis (namely, 24-hour intraluminal bile monitoring) and therapeutic management. Duodenogastric reflux (DGR) consists of retrograde passage of alkaline duodenal contents into the stomach; it may occur due to antroduodenal motility disorder (primary DGR) or may arise following surgical alteration of gastoduodenal anatomy or because of biliary pathology (secondary DGR). Pathologic DGR may generate symptoms of epigastric pain, nausea, and bilious vomiting. In patients with concomitant gastroesophageal reflux, the backwash of duodenal content into the lower esophagus can cause mixed (alkaline and acid) reflux esophagitis, and lead, in turn, to esophageal mucosal damage such as Barrett's metaplasia and adenocarcinoma. The treatment of DGR is difficult, non-specific, and relatively ineffective in controlling symptoms. Proton pump inhibitors decrease the upstream effects of DGR on the esophagus by decreasing the volume of secretions; promotility agents diminish gastric exposure to duodenal secretions by improving gastric emptying. In patients with severe reflux resistant to medical therapy, a duodenal diversion operation such as the duodenal switch procedure may be indicated

Chirurgie après chimioradiothérapie des cancers de l’œsophage : faut-il la faire ou pas ?

International audienceThe treatment of locally advanced esophageal cancer is still evolving. Surgery was considered as the backbone of the therapeutic management for a long time. Nowadays, chemoradiation has taken a major place in the neoadjuvant setting or as an exclusive treatment. Although some patients benefit from esophagectomy after chemoradiotherapy, a large subset of patients has no benefit and morbi-mortality rates are increased with a trimodality strategy. Patients who will have a local failure are at high risk of distant metastases in the follow-up. A third group of patients will have persistent locoregional disease after chemoradiotherapy and may benefit from surgery, but only a minority of patients with locally advanced disease are eligible. The impact of surgery after upfront chemoradiotherapy on survival and the quality of life of patients with locally advanced squamous cell esophageal cancer remain uncertain. An active surveillance strategy after chemoradiation or salvage esophagectomy for a locally residual disease might improve the prognosis of these patients. An optimized bimodality such as chemoradiotherapy delivering at least 50 Gy is still standard and salvage surgery for local persistent disease or a local failure must be discussed in the framework of a multidisciplinary group for selected patients only. (C) 2018 Societe francaise de radiotherapie oncologique (SFRO). Published by Elsevier Masson SAS. All rights reserved.Le traitement du cancer de l’œsophage localement évolué continue d’évoluer. La chirurgie a longtemps été considérée comme le seul traitement standard, mais la chimioradiothérapie a pris une place majeure dans la stratégie thérapeutique, soit en situation préopératoire, soit à visée exclusive. Bien que certains patients bénéficient toujours de la chirurgie après chimioradiothérapie, il existe encore un large sous-groupe de patients qui n’en bénéficient pas et qui pourraient être exposés à un risque de morbi-motalité accrue avec un traitement trimodal. Les patients atteints d’un résidu local sont plus à risque d’évolution métastatique, quel que soit le contrôle local obtenu. Il existe un troisième groupe de patients qui va être atteint d’une maladie locorégionale résiduelle seule après chimioradiothérapie exclusive. Ce sous-groupe représentant une minorité des patients atteints d'un cancer localement évolué au moment du diagnostic, pourrait bénéficier d’une chirurgie du résidu ou de la récidive locorégionale. L’impact sur la survie et la qualité de vie de la chirurgie étant encore incertains chez une majorité des patients atteints d’un carcinome épidermoïde ou d’un cancer localement évolué non résécable d’emblée, avec une stratégie de surveillance ou de chirurgie décalée à la récidive locorégionale le pronostic pourrait être plus favorable. Une bimodalité optimisée de chimioradiothérapie (de ≥50 Gy) doit donc restée indiquée en première intention et la chirurgie de rattrapage discutée au cas par cas pour quelques patients sélectionnés

Anastomotic leakage after gastrointestinal surgery: Diagnosis and management

International audienc

Characterization of hepatocellular carcinoma and colorectal liver metastasis by means of perfusion MRI

articl

Focal nodular hyperplasia and hepatocellular adenoma: The value of shear wave elastography for differential diagnosis

[DOI:\hrefhttps://dx.doi.org/10.1016/j.ejrad.2015.07.02910.1016/j.ejrad.2015.07.029] [PubMed:\hrefhttps://www.ncbi.nlm.nih.gov/pubmed/2629932326299323]This study assessed the clinical usefulness of shear wave elastography (SWE) during ultrasound for differentiating between focal nodular hyperplasias (FNHs) and hepatocellular adenomas (HAs).\ SWE was performed on 56 patients presenting with 76 liver lesions (57 FNHs and 19HAs) that were confirmed by MRI and contrast-enhanced ultrasound (CEUS) (n=55) or by histology (n=21). A mean elasticity value was obtained for each lesion. The ratios of the elasticity of the lesions to the elasticity of the surrounding liver were determined. The optimal elasticity cut-off value for distinguishing between the two lesion types was determined using ROC analysis. All lesions that were classified as "undetermined" after CEUS were reclassified using the elasticity values.\ The mean elasticity value was 46.99 ± 31.15 kPa for FNHs and 12.08 ± 10.68 kPa for HAs (p<0.0001). The mean relative elasticity ratio values were 7.94 ± 6.43 and 1.91 ± 1.70, respectively (p<0.0001). The ROC analysis showed a maximal accuracy of 95% for identification with a cut-off of 18.8 kPa for lesion elasticity (accuracy of 96% with a cut-off of 1.98 for the relative elasticity ratio). A total of 68 CEUS were performed, and 17 lesions (25%) were classified as "undetermined" after CEUS. With these cut-off values 16 lesions (94.1%) were correctly reclassified as FNHs.\ SWE is a useful adjunctive tool for differentiation between FNH and HA during ultrasound examination

Résections pancréatiques par laparoscopie

[Laparoscopic pancreatic resections] The faisability of laparoscopic pancreatic resection has been demonstrated. However, the real clinical benefit for the patients remains questioned. The best indication for a laparoscopic approach appears to be the resection of benign or neuro-endocrine tumors without a need for pancreato-enteric reconstruction (i.e enucleation or distal pancreatectomy). The use of the laparoscopic approach for malignant tumors still remains controversial. The benefits of minimally invasive surgery are clearly correlated with the successful management of the pancreatic stump. Pancreatic related complication rate (fistula and collection) is 15% when using pancreatic transection with a laparoscopic endostappler. (C) 2003 Editions scientifiques et medicales Elsevier SAS. Tous droits reserves

Phase-contrast MRI evaluation of haemodynamic changes induces by a coeliac axis stenosis in the gastroduodenal artery

International audiencebjective: To evaluate the correlation between the gastroduodenal artery (GDA) haemodynamic changes and the degree of coeliac axis (CA) stenosis using phase-contrast MRI.Methods: The study was institutional review board approved, and written informed consent was obtained from patients included prospectively. A two-dimensional phase-contrast MRI was performed in 23 patients scheduled for a potential complex supramesocolic surgery, in a plane perpendicular to the GDA, during inspiration and expiration. The peak and mean velocities (V-p and V-m), mean flow rate (Q(m)) and flow direction at inspiration and at expiration have been correlated with the degree of CA stenosis evaluated by CT.Results: 13 of 23 patients presented CA stenosis due to the median arcuate ligament (34-80% of stenosis), 4 of them had associated atheromatous calcifications. Vp, Vm and Qm of GDA presented a significant and linear relationship with the degree of CA stenosis, at inspiration as well as at expiration (r > 0.74, p 60% of stenosis (n=5), a reverse flow direction with increased velocities and flow rates were observed; variable patterns between 34% and 60%.Conclusion: Phase-contrast MRI permits the evaluation of haemodynamic changes in GDA induced by CA stenosis, including median arcuate ligament compression, and could be of great interest in therapeutic decision making in supramesocolic surgery, such as liver transplantation or duodenopancreatectomy, by detecting haemodynamically significant stenoses