Benjamin Castel

Iterative Cytoreductive Surgery Associated With Hyperthermic Intraperitoneal Chemotherapy for Treatment of Peritoneal Carcinomatosis of Colorectal Origin With or Without Liver Metastases

Introduction:The aim of this study was to evaluate the results of an aggressive strategy in patients presenting peritoneal carcinomatosis (PC) from colorectal cancer with or without liver metastases (LMs) treated with cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Patients and Methods:The population included 43 patients who had 54 CS+HIPEC for colorectal PC from 1996 to 2006. Sixteen patients (37%) presented LMs. Eleven patients (25%) presented occlusion at the time of PC diagnosis. Ascites was present in 12 patients (28%). Seventy-seven percent of the patients were Gilly 3 (diffuse nodules, 5–20 mm) and Gilly 4 (diffuse nodules>20 mm). The main endpoints were morbidity, mortality, completeness of cancer resection (CCR), and actuarial survival rates. Results:The CS was considered as CCR-0 (no residual nodules) or CCR-1 (residual nodules <5 mm) in 30 patients (70%). Iterative procedures were performed in 26% of patients. Three patients had prior to CS + HIPEC, 10 had concomitant minor liver resection, and 3 had differed liver resections (2 right hepatectomies) 2 months after CS + HIPEC. The mortality rate was 2.3% (1 patient). Seventeen patients (39%) presented one or multiple complications (per procedure morbidity = 31%). Complications included deep abscess (n = 6), wound infection (n = 5), pleural effusion (n = 5), digestive fistula (n = 4), delayed gastric emptying syndrome (n = 4), and renal failure (n = 3). Two patients (3.6%) were reoperated. The median survival was 38.4 months (CI, 32.8–43.9). Actuarial 2- and 4-year survival rates were 72% and 44%, respectively. The survival rates were not significantly different between patients who had CS + HIPEC for PC alone (including the primary resection) versus those who had associated LMs resection (median survival, 35.3 versus 36.0 months, P = 0.73). Conclusion:Iterative CS + HIPEC is an effective treatment in PC from colorectal cancer. The presence of resectable LMs associated with PC does not contraindicate the prospect of an oncologic treatment in these patients.

Long-term evolution of nutritional deficiencies after gastric bypass: an assessment according to compliance to medical care.

Objective:To study long-term nutritional deficits based on adherence to a standardized nutritional care after gastric bypass (GBP). Background:Long-term prospective data on nutritional complications after GBP are missing. It is not known whether severe deficiencies are prevented by standard multivitamin supplementation and what parameters are influenced by patient adherence to nutritional care. Design:One hundred forty-four consecutive subjects from our prospective database (90% women, initial body mass index: 48 ± 15 kg/m2, age: 43 ± 10 years) who underwent GBP more than 3 years before the study were assessed. Multivitamins were systematically prescribed after GBP, and additional supplements were introduced if deficiencies were recorded during follow-up. We identified a group of 66 compliant subjects who attended yearly medical visits and a group of 32 noncompliant subjects who were recalled because they had not attended any visit for more than 2 years. Results:Weight loss was 42 ± 14 kg at 3 years or later. The number of nutritional deficits per subject was 3.2 ± 2.3 before surgery and did not significantly increase between 1 and 3 years or later after GBP (3.4 ± 2.0 and 3.5 ± 2.3, respectively). However, specific nutritional deficits occurred despite long-term multivitamin supplementation, including vitamins B1, B12, and D and iron. Noncompliant subjects had more deficits than compliant subjects (4.2 ± 1.9 vs 2.9 ± 2.0 deficits per patient, P < 0.01) and the number of deficits correlated with the time from last visit (r = 0.285, P < 0.01). Conclusions:Lifelong medical care is required to maintain a good nutritional status after GBP. Monitoring of nutritional parameters is necessary to add supplementation for deficits that are not prevented by multivitamin preparations.

Cytoreductive surgery associated to hyperthermic intraperitoneal chemoperfusion for desmoplastic round small cell tumor with peritoneal carcinomatosis in young patients.

PURPOSE Desmoplastic round small cell tumor (DRSCT) is a rare intraabdominal mesenchymal tissue neoplasm in young patients and spreads through the abdominal cavity. Its prognosis is poor despite a multimodal therapy including chemotherapy, radiotherapy, and surgical cytoreduction (CS). hyperthermic intraperitoneal chemotherapy (HIPEC) is considered as an additional strategy in the treatment of peritoneal carcinomatosis; for this reason, we planned to treat selected cases of children with DRSCT using CS and HIPEC. METHODS Peritoneal disease extension was evaluated according to Gilly classification. Surgical cytoreduction was considered as completeness of cytoreduction-0 when no macroscopic nodule was residual; HIPEC was performed according to the open technique. RESULTS We described 3 cases: the 2 first cases were realized for palliative conditions and the last one was operated on with curative intent. There was no postoperative mortality. One patient was reoperated for a gallbladder perforation. There was no other complication related to HIPEC procedure. CONCLUSIONS Surgical cytoreduction and HIPEC provide a local alternative approach to systemic chemotherapy in the control of microscopic peritoneal disease in DRSCT, with an acceptable morbidity, and may be considered as a potential beneficial adjuvant waiting for a more specific targeted therapy against the fusion protein.

Human white and brite adipogenesis is supported by MSCA1 and is impaired by immune cells.

Obesity‐associated inflammation contributes to the development of metabolic diseases. Although brite adipocytes have been shown to ameliorate metabolic parameters in rodents, their origin and differentiation remain to be characterized in humans. Native CD45−/CD34+/CD31− cells have been previously described as human adipocyte progenitors. Using two additional cell surface markers, MSCA1 (tissue nonspecific alkaline phosphatase) and CD271 (nerve growth factor receptor), we are able to partition the CD45−/CD34+/CD31− cell population into three subsets. We establish serum‐free culture conditions without cell expansion to promote either white/brite adipogenesis using rosiglitazone, or bone morphogenetic protein 7 (BMP7), or specifically brite adipogenesis using 3‐isobuthyl‐1‐methylxanthine. We demonstrate that adipogenesis leads to an increase of MSCA1 activity, expression of white/brite adipocyte‐related genes, and mitochondriogenesis. Using pharmacological inhibition and gene silencing approaches, we show that MSCA1 activity is required for triglyceride accumulation and for the expression of white/brite‐related genes in human cells. Moreover, native immunoselected MSCA1+ cells exhibit brite precursor characteristics and the highest adipogenic potential of the three progenitor subsets. Finally, we provided evidence that MSCA1+ white/brite precursors accumulate with obesity in subcutaneous adipose tissue (sAT), and that local BMP7 and inflammation regulate brite adipogenesis by modulating MSCA1 in human sAT. The accumulation of MSCA1+ white/brite precursors in sAT with obesity may reveal a blockade of their differentiation by immune cells, suggesting that local inflammation contributes to metabolic disorders through impairment of white/brite adipogenesis. Stem Cells 2015;33:1277–1291

Lésions précancéreuses de la vésicule biliaire

This Mini-review summarizes the epidemiology, predisposing and pre-cancerous conditions related to carcinoma of the gallbladder. In 75% of cases, gallbladder cancer is a cholangiocarcinoma, usually presenting in a late and advanced stage, and it carries one of the worst prognoses of all GI malignancies. Early stage disease is usually discovered incidentally by the pathologist in a gallbladder specimen removed for calculous cholecystitis. It occurs three times more frequently in women than in men and invasive forms usually occur after the age of 60. Incidence varies with geographic location. Besides genetic and geographic factors, the presence of one or more large gallstones is a major risk factor. Gallbladder polyps larger than 1.5 cm. (especially solitary sessile hypoechogenic polyps) are associated with a 50% risk of malignancy. Choledochal cysts and other variations of the biliopancreatic junction are also associated with high risk; cancer may occur at a much younger age in these patients and in the absence of gallstones. Porcelain gallbladder is a risk factor, particularly when there is calcification of the gallbladder mucosa. Chronic gallbladder infection has been implicated as a risk factor for malignant degeneration. Finally, cancer of both the gallbladder and the bile ducts is more frequent in patients suffering from primary biliary cirrhosis.

Temporary Restoration of Digestive Continuity After Laparoscopic Gastric Bypass to Allow Endoscopic Sphincterotomy and Retrograde Exploration of the Biliary Tract

The prevalence of morbid obesity is rapidly increasing worldwide. As surgery has been recognized to be the only effective treatment for morbid obesity, the number of bariatric procedure realized each year has dramatically increased. Among all the surgical options, gastric bypass in considered as the gold standard. A possible drawback of this operation is the difficult access to the excluded proximal intestinal tract and, consequently, to the biliary tract. As gallstone formation may be frequent after a rapid weight loss induced by surgery, surgeons could be frequently asked to face the need of exploration of the biliary tree after anatomical changes induced by this kind of surgery. Many technical solutions, mainly based on a combined laparoscopic and endoscopic approach, have been proposed by several authors to face this problem. We herein describe an original technique to allow endoscopic exploration of biliary tract after a laparoscopic gastric bypass based on temporary restoration of physiological digestive continuity followed by re-establishment of the Roux-en-Y loop.

Syndrome fissuraire d'un pseudoanévrisme de l'artère gastroduodénale au contact d'un faux-kyste pancréatique : une complication rare mais grave de la pancréatite chronique

Most pseudoaneurysms (PsA) of the peripancreatic arteries cause direct erosion of the arterial wall from pancreatic enzymes that are usually in contact with or in a pseudocyst (PC). Rupturing is a rare and serious complication (90% mortality if untreated). We report the case of a 56-year-old patient with chronic alcoholic pancreatitis who developed a cephaloisthmic PC, complicated with a PsA of the gastroduodenal artery revealed by pain and deglobulization associated with cholestasis. After a diagnostic scan, emergency selective arteriography with coil embolization was performed. Five days later, hemorrhage recurred and a cephalic duodenopancreatectomy was performed. PsA of the gastroduodenal artery occur in the first 10 years of chronic pancreatitis. They are revealed by abdominal pains and/or gastrointestinal hemorrhage or shock from rupture. A scan with arterial reconstruction provides diagnosis. Arteriography is the most sensitive technique to locate the aneurysm and its branches and to perform selective embolization with coils. The failure rate is between 0 and 23%. Surgical treatment (elective ligation of the artery or partial pancreatic excision) should be limited to when embolisation fails and/or recurrent hemorrhage.