Bernard Sastre

External pancreatic duct stent decreases pancreatic fistula rate after pancreaticoduodenectomy: prospective multicenter randomized trial.

Objective: Pancreatic fistula (PF) is a leading cause of morbidity and mortality after pancreaticoduodenectomy (PD). The aim of this multicenter prospective randomized trial was to compare the results of PD with an external drainage stent versus no stent. Methods: Between 2006 and 2009, 158 patients who underwent PD were randomized intraoperatively to either receive an external stent inserted across the anastomosis to drain the pancreatic duct (n = 77) or no stent (n = 81). The criteria of inclusion were soft pancreas and a diameter of wirsung <3 mm. The primary study end point was PF rate defined as amylase-rich fluid (amylase concentration >3 times the upper limit of normal serum amylase level) collected from the peripancreatic drains after postoperative day 3. CT scan was routinely done on day 7. Results: The 2 groups were comparable concerning demographic data, underlying pathologies, presenting symptoms, presence of comorbid illness, and proportion of patients with preoperative biliary drainage. Mortality, morbidity, and PF rates were 3.8%, 51.8%, and 34.2%, respectively. Stented group had a significantly lower overall PF (26% vs. 42%; P = 0.034), morbidity (41.5% vs. 61.7%; P = 0.01), and delayed gastric emptying (7.8% vs. 27.2%; P = 0.001) rates compared with nonstented group. Radiologic or surgical intervention for PF was required in 9 patients in the stented group and 12 patients in the nonstented group. There were no significant differences in mortality rate (3.7% vs. 3.9%; P = 0.37) and in hospital stay (22 days vs. 26 days; P = 0.11). Conclusion: External drainage of pancreatic duct with a stent reduced. PF and overall morbidity rates after PD in high risk patients (soft pancreatic texture and a nondilated pancreatic duct). This study is registered at http://www.clinicaltrials.gov: Clinical trial ID# NCT01068886.

Incidence and prevention of ventral incisional hernia

OBJECTIVE Ventral incisional hernia is a common complication of abdominal surgery. The incidence ranges from 2% to 20% and varies greatly from one series to another. The goal of this study was to determine the incidence, risk factors, and preventive measures for ventral incisional hernia. MATERIALS AND METHODS An analysis of the surgical literature was performed using the search engines EMBASE, Cochrane Library, and PubMed with the keywords: abdominal hernia, wound dehiscence, incisional hernia, incidence, trocar site hernia, and hernia prevention. RESULTS The overall incidence of incisional hernia after laparotomy was 9.9%. The incidence was significantly higher for midline incisions compared with transverse incisions (11% vs. 4.7%; P=0.006). In contrast, the incidence of ventral hernia was only 0.7% after laparoscopy. A compilation of all the studies comparing laparotomy to laparoscopy showed a significantly higher incidence of incisional hernia after laparotomy (P=0.001). Independent risk factors for incisional hernia included age and infectious complications. Only two meta-analyses were able to show a significant decrease in risk-related to the use of non absorbable or slowly absorbable suture material. No difference in incisional hernia risk was shown with different suture techniques (11.1% for running suture, 9.8% for interrupted sutures: NS). CONCLUSION A review of the literature shows that only the choice of incisional approach (transverse incision or laparotomy vs. midline laparotomy) allows a significant decrease in the incidence of ventral incisional hernia.

Intraductal papillary or mucinous tumors (IPMT) of the pancreas: Report of a case series and review of the literature

OBJECTIVES:Despite a better understanding of these co intraductal papillary or mucinous tumors (IPMT) of the pancreas still present difficulty relating to the predictive factors of malignancy and the risk of relapse after surgical resection. The aim of this study was to report on our experience and to compare it to previously published cases.METHODS:We studied retrospectively 26 patients (mean age 60.3 yr) presenting with IPMT. Of the 26 patients, 19 had surgical resection and seven did not. The main clinical feature was acute pancreatitis occurring in 38% of the patients. Segmental pancreatectomy was performed in all the cases. At pathological assessment of resection margins, tumor resection was considered as complete in 17 cases. Margins exhibited benign mucinous involvement, and resection was considered to be incomplete in one multifocal case and in one case with diffuse spread of the tumor.RESULTS:A total of 11 tumors were benign and five were malignant. Carcinomas were invasive in four cases (two invading the pancreatic parenchyma, one the duodenum, and one the peripancreatic nodes) and in situ in one case. Malignancy was not diagnosed preoperatively except when invasion was evident (duodenal spread). Although main pancreatic duct type and obstructive jaundice appeared as suggestive features for the risk of malignancy, no reliable preoperative predictive factors for malignancy could be identified as regarding to clinical parameters, biological examinations, carcinoembryonic antigen or CA19-9 levels in serum or in pure pancreatic juice, imaging, and cytological methods. Within 40.8 months mean follow-up after surgery (range 2–96 months), three patients (16%), two with malignant and one with benign tumor, had tumor relapse after respectively 7, 27, and 14 months. Margins were positive without malignant features in the two malignant cases and negative in the other case. Tumor relapse was malignant with diffuse spreading in the three cases, and the patients died within 34 months after surgical resection.CONCLUSIONS:Our series and the review of the literature indicate that preoperative indicators of malignancy in IPMT are still lacking. Concerning resection margins, complete tumor resection is usually possible by segmental pancreatectomy. Malignant relapses are not exceptional. Incomplete resection and diffuse or multifocal tumor represent poor prognostic factors. Total pancreatectomy should be considered in such cases.

Selection criteria for internal rectal prolapse repair by delorme's transrectal excision

PURPOSE: The aim of this study was to review our results of Delormes transrectal excision for internal rectal prolapse, with a view to determining preoperative selection criteria associated with a satisfactory outcome. METHODS: Between 1992 and 1998, 20 patients with internal rectal prolapse underwent Delormes transrectal excision. The last patient was excluded from the study because of a follow-up period shorter than six months. The remaining 19 patients were prospectively followed up and classified into two groups according to their preoperative selection criteria. Group I consisted of eight patients operated on between January 1992 and October 1993 who were selected for surgery after medical treatment during a three-month period failed to improve symptoms. Initial results were reviewed, with a follow-up of at least six months, to assess predictive criteria correlating with poorer surgical outcome. These adverse criteria were used to exclude patients from selection into Group II, which included 11 patients operated on between June 1994 and June 1997. In each group the degree of improvement of symptoms was graded: Grade 1 = complete improvement with resolution of all symptoms; Grade 2 = significant improvement with resolution of dyschezia but not of other symptoms; Grade 3 = no improvement; and Grade 4 = worsened condition or reoperation. The two groups were compared according to ultimate outcomes. RESULTS: Of the Group I patients, three had preoperative chronic diarrhea, one had proximal internal rectal prolapse with rectosacral separation at defecography, and the other two were incontinent to liquid stool. An additional patient had incontinence to liquid stool but no diarrhea. Three other patients had major perineal descent (>9 cm). Results were Grade 1 for one patient, Grade 2 for one patient, Grade 3 for five patients, and Grade 4 for one patient (subsequent abdominal rectopexy). Data review showed that proximal internal prolapse with rectosacral separation at defecography, preoperative chronic diarrhea, fecal incontinence, and descending perineum (>9 cm on straining) were associated with a poorer outcome (Grades 3 and 4). These adverse criteria were used to exclude patients from selection into Group II. In this group results were Grade 1 for seven patients and Grade 2 for four patients. During the course of follow-up (mean, 43; standard deviation, 19; range, 8–73 months), outcome was better in Group II (P=0.007). CONCLUSION. These data suggest that a favorable outcome can be achieved after Delormes transrectal excision for internal rectal prolapse by applying stringent patient-selection criteria.

Frey procedure in the treatment of chronic pancreatitis: short-term results.

Objective: The aim of this multicenter study was to report the short-term results of the Frey procedure in the treatment of chronic pancreatitis. Methods: For the period between September 2000 and January 2005, 34 Frey procedures were performed for chronic pancreatitis in 4 university hospitals. This study includes 31 men (91%) and 3 women (9%), with a mean age of 48 ± 6 years (range, 32-58 years). The etiology of chronic pancreatitis was chronic alcohol ingestion in 32 patients (94%) and hereditary chronic pancreatitis in 2 patients. The indications of surgery were abdominal pain in all patients, requiring opiates in 59% (n = 20) and associated with a weight loss in 79% (n = 27). Results: There was no mortality. Eleven postoperative surgical complications occurred in 7 patients (20%). Three patients had a single complication, and 4 patients had 2 complications. Pancreatic fistula occurred in 4 patients and healed under conservative management in all cases. One patient had massive bleeding from the stump of gastroduodenal artery requiring reoperation. The mean hospital stay was 16 ± 8 days (range, 9-40 days). The mean follow-up was 15 ± 12 months (range, 3-37 months). At the time of the last follow-up visit, the examiner judged that 19 patients (56%) have complete pain relief and 11 patients (32%) have substantial pain relief. No patient used narcotic analgesics postoperatively. Seven patients developed diabetes mellitus, requiring insulin (n = 1), oral hypoglycemic agents (n = 5), and diet adjustment (n = 1). Four patients developed exocrine insufficiency. Weight increases with a mean of 4.8 ± 5.4 kg (range, 1-24 kg) in 27 patients (79%). Conclusions: Frey procedure appears as a safe technique with low mortality and morbidity rates and allows effective pain relief in about 90% of patients.

Histone deacetylase (HDAC) encoding gene expression in pancreatic cancer cell lines and cell sensitivity to HDAC inhibitors.

Purpose: Multiple biochemical and molecular alterations occur in pancreatic cancer cells. In the present study, attempts were made for the first time, to explore the level of expression of members of histone deacetylase encoding genes (HDACs) in four pancreatic tumor cell lines: Panc-1, BxPC-3, SOJ-6 and MiaPaCa-2; and two non-related tumor cells: Jurkat and HeLa. Furthermore, we examined the possible relationship between the levels of HDACs expression and the sensitivity/resistance to HDAC inhibitors (TSA, Nicotinamide and Sirtinol). Methods: We have used four human pancreatic tumor cell lines and two-non related tumor cells, to evaluate the expression of HDAC encoding genes by RT-PCR and Western blot analysis. We also measured the effect of certain HDAC inhibitors (HDIs) on cell growth, cell cycle alteration, membrane phosphatidyl-serine exposure, DNA fragmentation, and mitochondrial membrane potential loss.Results: We have found that although a slight variation in the profiles of gene expression among cell lines could be evidenced, HDACs protein synthesis seem to be similar. Furthermore, the cells were equally sensitive to inhibition by Sirtinol whereas some variation in the IC50 could be seen in the case of TSA. We also demonstrate that the drugs had the capacity to induce the death of cells by apoptosis. Conclusions: Taken together, our data support the notion that the level of cell sensitivity to the HDIs might be related to the level of expression of genes such as those encoding proteins playing a role in cell cycle checkpoints control but not HDAC per se.

Simultaneous bilateral oophorectomy does not improve prognosis of postmenopausal women undergoing colorectal resection for cancer

PURPOSE: Synchronous or metachronous ovarian metastases are common along the natural course of colorectal carcinoma. We attempted to prospectively assess the prognostic impact of simultaneous bilateral oophorectomy in postmenopausal women undergoing curative resection for colorectal cancer. METHODS: Between 1980 and 1990, simultaneous bilateral oophorectomy was proposed in each postmenopausal woman referred to our institution for treatment of colorectal cancer. A subset of 92 patients underwent a curative resection. Therefore, two groups were designed for comparison of the procedure. Group I included 41 patients who accepted surgical castration, and Group II consisted of the 51 remaining patients who refused. Prospective analysis of all patients was performed. Results were assessed with a follow-up of 60 months after surgery, with 97.9 percent completion. Local recurrence and liver metastases rates were compared by the chisquared test. Survival in each group was calculated by the Kaplan-Meier method and compared by the log-rank test. RESULTS: One patient (1/41; 2.4 percent) had ovarian metastases detected on the operative specimen. Local recurrence or liver metastases rates were not affected by oophorectomy (P=0.73;P=0.25). Five-year actuarial survival rates were not significantly different whether patients had oophorectomy (81.6 percent) or not (87.9 percent;P=0.62). CONCLUSIONS: Our results suggest that microscopic synchronous ovarian metastasis is rare at the time of curative resection of a colorectal carcinoma in postmenopausal women. Because simultaneous bilateral oophorectomy does not modify prognosis, this procedure seems to be unwarranted.

Long Term Results of Lateral Pancreaticojejunostomy for Chronic Alcoholic Pancreatitis

OBJECTIVE To assess our long term results of lateral pancreaticojejunostomy in patients with alcoholic pancreatitis. DESIGN Retrospective study. SETTING University hospital, France. SUBJECTS 57 patients (48 men, 9 women, mean (SD) age 46 (7) years who required surgical treatment of chronic alcoholic pancreatitis between January 1977 and October 1995. INTERVENTIONS Lateral pancreaticojejunostomy with or without another procedure. Outcome classified as excellent, good, fair, or poor. MAIN OUTCOME MEASURES Postoperative morbidity and mortality; relief of pain; reduction in use of analgesics and exocrine supplements; effect on exocrine and endocrine insufficiency; and return to paid work. RESULTS There were no postoperative deaths and no pancreatic fistulae, but there were 17 other postoperative complications (30%). Median follow up was 65 months (range 8-206), during which 12 patients died (21%). Result was judged excellent in 16 (28%), good in 27 (47%), fair in 5 (9%), and poor in 9 (16%). Pain control was significantly improved, analgesic usage decreased, less pancreatic enzyme supplementation was required, and 25 patients returned to paid work (p = 0.0001 in each case). Exocrine and endocrine function remained stable. The results were better if the patient gave up misusing alcohol (p = 0.03) and if the operation was done within 4 years of the development of pancreatitis (p = 0.03). CONCLUSIONS Lateral pancreaticojejunostomy is a safe procedure that can improve functional outcome in patients with chronic alcoholic pancreatitis, and does not worsen pancreatic function.

Long-Term Outcome After Ampullectomy for Ampullary Lesions Associated With Familial Adenomatous Polyposis

PURPOSEUp to 90 percent of patients with familial adenomatous polyposis develop adenomas in the upper gastrointestinal tract. Besides pancreaticoduodenectomy, which remains indicated in duodenal and ampullary cancer, less aggressive surgical procedure (such as ampullectomy) must be evaluated in selected patients with familial adenomatous polyposis patients presenting low-risk benign duodenal adenomas.METHODSFrom 1995 to 2000, we performed a retrospective, observational study, which included eight patients (5 females) with familial adenomatous polyposis underwent ampullectomy (with frozen sections) for presumed benign polyposis lesions. Six patients had an ileal pouch-anal anastomosis performed 2 to 27 years before ampullectomy. The remaining two patients had ampullectomy during the same operation than ileal pouch-anal anastomosis.RESULTSNo patient died postoperatively. Mean hospital stay was 15 ± 6.5 (range, 10–21) days. There was one major complication (pancreatic fistula), which was treated conservatively. Final pathologic examination of the specimens revealed that three patients had a severe dysplasia. Mean follow-up of the patients was 58 ± 37 (range, 24–119) months. During endoscopic follow-up, although all the patients underwent endoscopic resection of duodenal polyps, none presented recurrence at the ampullectomy site.CONCLUSIONSAmpullectomy could be safely proposed in selected familial adenomatous polyposis patients. Our low morbidity and the absence of recurrence after almost five years of follow-up suggests that such conservative treatment could be proposed before pancreaticoduodenectomy in patients with high-risk ampullary adenomas without invasive carcinoma.

Treatment of hepatic trauma with perihepatic mesh: 35 cases.

In a series of 61 trauma cases, 35 liver injuries (Moores classes 2 to 5) were repaired using a polyglactin 910 perihepatic prosthesis. Two deaths (one coma, one avulsion of the inferior vena cava) were observed. Two centrohepatic hematomas were successfully treated by percutaneous needle aspiration. No hemobilia and no abscess of the liver occurred. Rapidly obtained hemostasis and cholestasis result in a large savings of blood. Progressive disappearance of the lesions was observed with repeat CT scanning until full recovery of the parenchyma was achieved. This was verified by biopsy and histologic examination and also by means of specific hepatic function tests.