Carcinose péritonéale d'origine colique traitée par cytoréduction complète et chimiothérapie hyperthermique intrapéritonéale : efficacité de la Mitomycine C

Médecine. Chirurgie généraleLa survie des patients atteints de carcinose péritonéale d’origine colique peut être prolongée grâce à la cytoréduction complète (CRC) avec chimiothérapie hyperthermique intra-péritonéale (CHIP). Les centres spécialisés réalisant ce traitement ont employé depuis plusieurs années deux molécules : la Mitomycine C (MMC) et l’Oxaliplatine. L’essai prospectif randomisé PRODIGE 7 a néanmoins montré que la CHIP à l’Oxaliplatine administrée selon le protocole suivi en France n’apportait pas de bénéfice par rapport à la CRC seule. L’intérêt de cette étude était de comparer l’efficacité de la MMC par rapport à l’Oxaliplatine en termes de survie sans récidive, de survie sans récidive péritonéale et de survie globale. Nous avons mené une étude rétrospective monocentrique au sein de notre service de Chirurgie Générale et Digestive des Hôpitaux Universitaires de Strasbourg chez tous les patients enregistrés prospectivement qui ont bénéficié entre décembre 2004 et décembre 2019 d’une CRC avec CHIP à la MMC ou à l’Oxaliplatine pour une carcinose péritonéale d’origine colique. 137 patients ont été inclus. L’analyse univariée n’a pas permis de montrer de différence significative entre les deux produits en termes de survie sans récidive (p=0,960) et de survie globale (p=0,320). L’efficacité de la MMC a néanmoins pu être prouvée par l’intermédiaire d’un modèle pondéré par l’inverse de la probabilité de traitement, s’ajustant sur quatre paramètres cliniques et histologiques d’intérêt : la localisation de la tumeur primitive, le degré de différenciation tumorale, l’occurrence d’une chimiothérapie néo-adjuvante et le Peritoneal Cancer Index (PCI). Le hazard ratio à 0,74 est ainsi en faveur de la MMC pour une survie sans récidive, avec un intervalle de confiance de 95% à [0,56 - 0,98] et p=0.035, et le hazard ratio à 0,59 pour une survie sans récidive péritonéale, avec un intervalle de confiance de 95% à [0,40 – 0,88] et p=0,0084. Concernant la survie globale, l’analyse n’a pas décelé de bénéfice significatif de la MMC, avec un hazard ratio à 0,88 et p=0.56. Ces résultats permettent de soutenir l’hypothèse d’une supériorité de la MMC par rapport à l’Oxaliplatine en hyperthermie intra-péritonéale avec CRC pour un traitement curatif des carcinoses péritonéale d’origine colique.The survival of patients having a peritoneal carcinomatosis of colorectal origin can be extended due to the treatment by complete cytoreducttion (CCR) with hypertermic intraperitoneal chemotherapy (HIPEC). The specialized centers performing this treatment have used these two molecules for several years : Mitomycine C (MMC) and Oxaliplatine. However, the PRODIGE 7 prospective randomized clinical trial has shown that HIPEC using Oxaliplatine, as considered in the French protocol, does not achive better results in comparison with the complete cytoreduction used on its own. The purpose of our assesement was to compare the effectiveness of MMC versus Oxaliplatine in terms of disease-free survival, the peritoneal recurrence-free survival and the overall survival.Our retrospective monocentric study assesed all patients that were prospectively registered for having CCR with HIPEC using MMC or Oxaliplatine for peritoneal carcinomatosis of colorectal origin in our General and Digestive Surgery Department at Hopitaux Universitaires in Strasbourg. 137 patient were included in our database and thus in our study. Univariate analysis has not showed any significant difference between the two drugs in terms of disease-free survival (p=0, 960 and overall survival (p= 0, 32). Nevertheless, the efficiency of MMC has been proven by the intermediate of a statstic model as the opposite of probability of treatment adjusting four clinical and histological parameters of interest : the primary tumor localization, the degree of tumor cell differentiation, the occurrence of neoadjuvant chemotherapy and the peritoneal Cancer Index (PCI). The hazard ratio being at 0,74 is also in favour of the MMC for a peritoneal reccurence-free survival having the confidence interval of 95% et p=0,035. Also the hazard ratio at 0,59 for a peritoneal reccurence-free survival with a confidence interval at 95% ( 0,40-0,88) and p=0,0084. Considering the assesement of overall survival rate, the analysis has not shown any significant benefitof the MMC with a hazard ratio at 0,88 and p=0,56. These results offer us the arguments for emphasizing the hypothesis for the superiority of MMC in comparaison with Oxaliplatine in HIPEC with cytoreduction as a curative treatment for peritoneal carcinomatosis of colorectal origin

Risk factors for emergency surgery for diverticulitis: A retrospective multicentric French study at 41 hospitals

International audienceBackgroundThe observed increase in the incidence of complicated diverticulitis may lead to the performance of more emergency surgeries. This study aimed to assess the rate and risk factors of emergency surgery for sigmoid diverticulitis.MethodThe primary outcomes were the rate of emergency surgery for sigmoid diverticulitis and its associated risk factors. The urgent or elective nature of the surgical intervention was provided by the surgeon and in accordance with the indication for surgical treatment. A mixed logistic regression with a random intercept after multiple imputations by the chained equation was performed to consider the influence of missing data on the results.ResultsBetween 2010 and 2021, 6,867 patients underwent surgery for sigmoid diverticulitis in the participating centers, of which one-third (n = 2317) were emergency cases. In multivariate regression analysis with multiple imputation by chained equation, increasing age, body mass index <18.5 kg/m2, neurologic and pulmonary comorbidities, use of anticoagulant drugs, immunocompromised status, and first attack of sigmoid diverticulitis were independent risk factors for emergency surgery. The likelihood of emergency surgery was significantly more frequent after national guidelines, which were implemented in 2017, only in patients with a history of sigmoid diverticulitis attacks.ConclusionThe present study highlights a high rate (33%) of emergency surgery for sigmoid diverticulitis in France, which was significantly associated with patient features and the first attack of diverticulitis

Impact of the first wave of COVID-19 epidemy on the surgical management of sigmoid diverticular disease in France: National French retrospective study

International audienceObjective: To analyze the surgical management of sigmoid diverticular disease (SDD) before, during, and after the first containment rules (CR) for the first wave of COVID-19.Methods: From the French Surgical Association multicenter series, this study included all patients operated on between January 2018 and September 2021. Three groups were compared: A (before CR period: 01/01/18-03/16/20), B (CR period: 03/17/20-05/03/20), and C (post CR period: 05/04/20-09/30/21).Results: A total of 1965 patients (A n = 1517, B n = 52, C n = 396) were included. The A group had significantly more previous SDD compared to the two other groups (p = 0.007), especially complicated (p = 0.0004). The rate of peritonitis was significantly higher in the B (46.1%) and C (38.4%) groups compared to the A group (31.7%) (p = 0.034 and p = 0.014). As regards surgical treatment, Hartmann's procedure was more often performed in the B group (44.2%, vs A 25.5% and C 26.8%, p = 0.01). Mortality at 90 days was significantly higher in the B group (9.6%, vs A 4% and C 6.3%, p = 0.034). This difference was also significant between the A and B groups (p = 0.048), as well as between the A and C groups (p = 0.05). There was no significant difference between the three groups in terms of postoperative morbidity.Conclusion: This study shows that the management of SDD was impacted by COVID-19 at CR, but also after and until September 2021, both on the initial clinical presentation and on postoperative mortality

Comparison of surgical management and outcomes of acute right colic and sigmoid diverticulitis: a French national retrospective cohort study

International audienceBackground: Acute right colic diverticulitis (ARD) is less frequent in Western countries than acute sigmoid diverticulitis (ASD). We aimed to compare the management of ARD and ASD operated on in emergency.Methods: All consecutive patients who had emergency surgery for ASD and ARD (2010-2021) were included in a retrospective, multicenter, cohort study. Patients were identified from databases in French centers that were members of the French Surgical Association. Emergency surgery was performed during the same hospitalization for peritonitis or after failure of conservative treatment. Early and late postoperative outcomes were studied.Results: A total of 2297 patients were included with 2256 (98.2%) ASD and 41 (1.8%) ARD patients. Baseline characteristics were similar. Overall, patients were rated Hinchey 3-4 (63.9%, n = 1468, p = 0.287). ARD was more often treated with resection and anastomosis, protected or not (53.7%, n = 22), whereas ASD was mainly treated with resection and terminal ostomy (62.5% (n = 1409), p < 0.001). Median operative time was shorter for ARD (120 vs 146 min, p = 0.04). The group of ARD patients showed a higher prevalence of Clavien III/IV complications compared to the group of ASD patients, although no statistically significant difference was observed (41.5%, n = 17 vs. 27.6%, n = 620, p = 0.054). However 90-day mortality only happened in ASD patients (9.8%, n = 223 vs 0, p = 0.03). ARD patients had more diverticulitis recurrence (46.3%, n = 19 vs 13.4%, n = 303, p < 0.001). Multivariate analysis identified female sex as a protective factor for recurrence [odds ratio (OR) 0.55, p < 0.001] and ARD as a risk factor (OR 8.85, p < 0.001).Conclusion: Operated on in emergency, ARDs have more resection anastomosis, with a similar rate of complications, less mortality, and more recurrence of diverticulitis than ASD

Chronic coronary syndromes without standard modifiable cardiovascular risk factors and outcomes: the CLARIFY registry

Background and Aims: It has been reported that patients without standard modifiable cardiovascular (CV) risk factors (SMuRFs—diabetes, dyslipidaemia, hypertension, and smoking) presenting with first myocardial infarction (MI), especially women, have a higher in-hospital mortality than patients with risk factors, and possibly a lower long-term risk provided they survive the post-infarct period. This study aims to explore the long-term outcomes of SMuRF-less patients with stable coronary artery disease (CAD). Methods: CLARIFY is an observational cohort of 32 703 outpatients with stable CAD enrolled between 2009 and 2010 in 45 countries. The baseline characteristics and clinical outcomes of patients with and without SMuRFs were compared. The primary outcome was a composite of 5-year CV death or non-fatal MI. Secondary outcomes were 5-year all-cause mortality and major adverse cardiovascular events (MACE—CV death, non-fatal MI, or non-fatal stroke). Results: Among 22 132 patients with complete risk factor and outcome information, 977 (4.4%) were SMuRF-less. Age, sex, and time since CAD diagnosis were similar across groups. SMuRF-less patients had a lower 5-year rate of CV death or non-fatal MI (5.43% [95% CI 4.08–7.19] vs. 7.68% [95% CI 7.30–8.08], P = 0.012), all-cause mortality, and MACE. Similar results were found after adjustments. Clinical event rates increased steadily with the number of SMuRFs. The benefit of SMuRF-less status was particularly pronounced in women. Conclusions: SMuRF-less patients with stable CAD have a substantial but significantly lower 5-year rate of CV death or non-fatal MI than patients with risk factors. The risk of CV outcomes increases steadily with the number of risk factors