Emmanuel Huet

Life-threatening postoperative pancreatic fistula (grade C) after pancreaticoduodenectomy: incidence, prognosis, and risk factors.

BACKGROUND Pancreatic fistula (PF) is one of the most common postoperative complications of pancreatoduodenectomy (PD). A recent International Study Group on Pancreatic Fistula (ISGPF) definition grades the severity of PF according to the clinical impact on the patients hospital course. Although PF is generally treated conservatively (grade A), some cases may require interventional procedures (grade B) or may be life-threatening and necessitate emergency reoperation (grade C). The aim of the present study was to evaluate the incidence of postoperative grade C PF after PD and to assess the prognosis and risk factors for this life-threatening condition. STUDY DESIGN Between January 2000 and December 2006, 680 consecutive patients underwent PD in 5 digestive surgery departments in the northwest region of France (Lille, Amiens, Rouen, and Caen). PF was defined as drain output of any measurable volume of fluid on or after postoperative day 3 with amylase content greater than 3 times the serum amylase activity (ISGPF guidelines). To identify possible risk factors for grade C PF, we reviewed the records of 111 (16.3%) patients with postoperative PF and compared grade C cases with grade A+B cases. RESULTS The median age was 59 years (range 22-87). The male-to-female ratio was 1.6:1. Fifty-six (50.4%) PDs were performed via pancreaticogastrostomy and 55 via pancreaticojejunostomy. Overall mortality was 2% (n = 14). Grade C PF was observed in 36 (32%) patients, of whom 17 (47%) had sepsis due to an abdominal collection, 16 (44%) had postoperative bleeding, 10 (27.7%) had bleeding associated with abdominal collection, and 3 (9%) had multi-organ failure due to other causes. Of these 36 patients, 35 (97%) underwent reoperation. The mortality rate in grade C PF patients was 38.8%. The major causes of death were sepsis (n = 6) and recurrent bleeding after reoperation (n = 5). Grade C PF increased the duration of postoperative hospitalization (46 vs 29 days, P < .001). Univariate analysis showed that peroperative soft pancreatic parenchyma, peroperative blood transfusion, and postoperative bleeding were significant risk factors for grade C PF, with P values of .011, .003, and .001, respectively. No risk factors for grade C PF were identified in a multivariate analysis. The sensibility, specificity, positive predictive value, and negative predictive value of the presence of the 3 risk factors for grade C PF were 13.89%, 100%, 100%, and 70.75%, respectively. CONCLUSION Sixteen percent of patients had PF after PD. Among them, 30% had grade C PF, with a mortality rate of about 40%. Achievement of a 100% predictive positive value for grade C PF after PD in individuals with 3 discriminant risk factors (peroperative soft pancreatic parenchyma, peroperative transfusion, and postoperative bleeding) is a first step towards the identification of high-risk patients who should be managed differently from other patients with PF during or after PD.

Recurrences and fertility after endometrioma ablation in women with and without colorectal endometriosis: a prospective cohort study

STUDY QUESTION What are the recurrence and pregnancy rates in women managed for ovarian endometrioma by ablation using plasma energy with and without associated surgery for colorectal endometriosis? SUMMARY ANSWER Concomitant management of colorectal endometriosis does not impact either risk of recurrences or probability of pregnancy in women managed for endometrioma ablation using plasma energy. WHAT IS KNOWN ALREADY No consensus exists on how best to manage patients presenting with ovarian endometriomas and colorectal endometriosis, in terms of impact on fertility preservation and recurrence rates. STUDY DESIGN, SIZE, DURATION A prospective series of consecutive patients managed for ovarian endometriomas by ablation using plasma energy, over a period of 48 consecutive months. The study included patients with associated colorectal endometriosis (n = 52) and those who were free of colorectal localizations of the disease (n = 72). No women were lost to follow-up. PARTICIPANTS/MATERIALS, SETTING, METHODS The 124 women included in this study were managed for either unilateral or bilateral ovarian endometriomas using plasma energy at a university tertiary care center. Recurrences and pregnancy rate were compared in patients with and without colorectal endometriosis. The minimum length of follow-up was 1 year. Cyst recurrences were assessed using pelvic ultrasound and magnetic resonance imaging. Kaplan-Meier and actuarial life-table analysis were used to estimate the recurrence-free survival curve and the probability of pregnancy. The Cox model was used to assess independent predictive factors for recurrences. Pregnancy likelihood and independent predictors were estimated using a regression logistic model. MAIN RESULTS AND THE ROLE OF CHANCE Mean follow-up was 32 ± 18 months. Forty-eight patients (40.3%) were presumed infertile and attended an assisted reproductive techniques (ART) center. Eighteen patients presented with a recurrence (14.5%). Bilateral localization of endometriomas was the only factor independently related to an increased risk of recurrences [hazard ratio 3.3, 95% confidence interval (CI) 1.2-9.4]. Of the 83 women wishing to conceive (66.9%), 51 became pregnant (61.4%) and 33 of these pregnancies were spontaneous (64.7%). The rates of pregnancy were 65.8% for the group of patients with associated colorectal endometriosis and 57.8% for controls (P = 0.50). Age over 35 years was the only independent factor for which association with pregnancy rates approached the significance threshold (adjusted odds ratio 0.35, 95% CI 0.12-1, P = 0.06). LIMITATIONS, REASONS FOR CAUTION The study sample size may be insufficient to reveal statistically significant differences related to risk factors which have low impact on the probability of recurrence and pregnancy. Data on ovarian reserve before and after the procedure was not available in all patients, which would have added to our results and the discussion about treatment of endometrioma in general. WIDER IMPLICATIONS OF THE FINDINGS Concomitant management of colorectal endometriosis does not impact either risk of recurrences or the probability of pregnancy in women having benefited from ovarian endometrioma ablation using plasma energy. Moreover, surgical management of colorectal and ovarian endometriosis may allow spontaneous conception in one out of three patients, thus reducing expenses related to ART management. STUDY FUNDING/COMPETING INTERESTS No financial support was received for this study. Horace Roman reports personal fees for participating in a symposium and masterclass presenting his experience in the use of PlasmaJet.

Long-Term Outcome of Liver Resection for Hepatocellular Carcinoma in Noncirrhotic Nonfibrotic Liver with No Viral Hepatitis or Alcohol Abuse

BackgroundHepatocellular carcinoma (HCC) occurs primarily in cirrhotic liver, with less than 10% occurring in normal liver parenchyma. Limited studies have described the outcome of liver resection in strictly normal liver parenchyma with no cirrhosis, fibrosis, underlying viral hepatitis, alcohol abuse, or dysmetabolic syndrome.Materials and methodsBetween January 1986 and 2005, a total of 321 patients were referred to our institution for HCC. Of these patients, 20 (6.2%) underwent surgery for HCC arising in noncirrhotic nonfibrotic liver parenchyma; they comprise our study group. Pathology examinations were reviewed based on the Chevallier fibrosis score and the Metavir viral score. Pre-, per-, and postoperative data were collected to assess their influence on tumor recurrence and survival.ResultsThe median age was 57 years (35–80 years), and 71% patients were male. α-Fetoprotein serum levels were normal in 9 patients. A preoperative diagnosis was made in 14 cases. Morbidity and morality rates were 10% and 5%, respectively. The 1-, 3-, and 5-year survival rates were 85%, 70%, and 64%, respectively; and disease-free survivals at 1, 3, and 5 years were 84%, 66%, and 58%, respectively. Eight patients had a recurrence with a median delay of 15 months (2–70 months). Univariate analysis showed that survival was influenced by preoperative cytolysis, R0 resection, recurrence, and recurrence within 1 year. A multivariate analysis revealed that recurrence and recurrence within 1 year significantly decreased survival. The 1-, 3-, and 5-year survival rates of patients with recurrence were 75%, 37%, and 25%, respectively.ConclusionThese results for HCC in patients with normal liver parenchyma justify liver resection and underline the differences in outcome of patients with HCC in a cirrhotic liver.

Comparison of the Effectiveness of Four Bariatric Surgery Procedures in Obese Patients with Type 2 Diabetes: A Retrospective Study

Aim. The aim of the present retrospective study was to evaluate the efficacy of four bariatric surgical procedures to induce diabetes remission and lower cardiovascular risk factors in diabetic obese patients. Moreover, the influence of surgery on weight evolution in the diabetic population was compared with that observed in a nondiabetic matched population. Methods. Among 970 patients who were operated on in our center since 2001, 81 patients were identified as type 2 diabetes. Laparoscopic adjustable gastric banding (GB), intervention type Mason (MA), gastric bypass (RYGB), and sleeve gastrectomy (SG) were performed, respectively, in 25%, 17%, 28%, and 30% of this diabetic population. Results. The resolution rate of diabetes one year after surgery was significantly higher after SG than GB (62.5% versus 20%, P < 0.01), but not significantly different between SG and RYGB. In terms of LDL-cholesterol reduction, RYGB was equivalent to SG and superior to CGMA or GB. Considering the other cardiovascular risk factors, there was no significant difference according to surgical procedures. The weight loss was not statistically different between diabetic and nondiabetic matched patients regardless of the surgical procedures used. Conclusion. Our data confirm that the efficacy of surgery to treat diabetes is variable among the diverse procedures and SG might be an interesting option in this context.

Early surgery for failure after chemoradiation in operable thoracic oesophageal cancer. Analysis of the non-randomised patients in FFCD 9102 phase III trial: Chemoradiation followed by surgery versus chemoradiation alone

BACKGROUND Two randomised trials concerning thoracic oesophageal cancer concluded that for squamous cell carcinoma, chemoradiation alone leads to the same overall survival (OS) as chemoradiation followed by surgery. One of these trials, FFCD 9102, randomised only fit, compliant and operable responders to induction chemoradiation between continuation of chemoradiation and surgery. In the present analysis, the outcome in the patients not eligible for randomisation was calculated to determine if attempt of surgery should be recommended. METHODS Eligible patients had operable T3-N0/N1-M0 thoracic oesophageal cancer. After initial chemoradiation, patients with no clinical response, or with contraindication to follow any attributed treatment, were not randomised. OS was studied first in the whole population of not randomised patients, and then specifically in clinical non-responders. The impact of surgery on OS was studied in these two populations. FINDINGS Of the 451 registered patients in the trial, 192 were not randomised. Among them, 111 were clinical non-responders. Median OS was significantly shorter for non-randomised patients (11.5 months) than for randomised patients (18.9 months; p=0.0024). However, for the 112 non-randomised patients who underwent surgery, median OS was not different from that in randomised patients: 17.3 versus 18.9 months (p=0.58). Concerning clinical non-responders, median OS was longer for those who underwent surgery compared to non-operated patients: 17.0 versus 5.5 months (hazard ratio (HR)=0.39 [0.25-0.61]; p<0.0001), and again was not different from that in responding, randomised patients (p=0.40). INTERPRETATION In patients with locally advanced thoracic oesophageal cancer, overall survival did not differ between responders to induction chemoradiation and patients having surgery after clinical failure of chemoradiation. Surgery should therefore be considered in those patients who are still operable.

Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial

Abstract STUDY QUESTION Is there a difference in functional outcome between conservative versus radical rectal surgery in patients with large deep endometriosis infiltrating the rectum 2 years postoperatively? SUMMARY ANSWER No evidence was found that functional outcomes differed when conservative surgery was compared to radical rectal surgery for deeply invasive endometriosis involving the bowel. WHAT IS KNOWN ALREADY Adopting a conservative approach to the surgical management of deep endometriosis infiltrating the rectum, by employing shaving or disc excision, appears to yield improved digestive functional outcomes. However, previous comparative studies were not randomized, introducing a possible bias regarding the presumed superiority of conservative techniques due to the inclusion of patients with more severe deep endometriosis who underwent colorectal resection. STUDY DESIGN SIZE, DURATION From March 2011 to August 2013, we performed a 2-arm randomized trial, enroling 60 patients with deep endometriosis infiltrating the rectum up to 15 cm from the anus, measuring more than 20 mm in length, involving at least the muscular layer in depth and up to 50% of rectal circumference. No women were lost to follow-up. PARTICIPANTS/MATERIALS, SETTING, METHODS Patients were enroled in three French university hospitals and had either conservative surgery, by shaving or disc excision, or radical rectal surgery, by segmental resection. Randomization was performed preoperatively using sequentially numbered, opaque, sealed envelopes, and patients were informed of the results of randomization. The primary endpoint was the proportion of patients experiencing one of the following symptoms: constipation (1 stool/>5 consecutive days), frequent bowel movements (≥3 stools/day), defecation pain, anal incontinence, dysuria or bladder atony requiring self-catheterization 24 months postoperatively. Secondary endpoints were the values of the Visual Analog Scale (VAS), Knowles–Eccersley–Scott-Symptom Questionnaire (KESS), the Gastrointestinal Quality of Life Index (GIQLI), the Wexner scale, the Urinary Symptom Profile (USP) and the Short Form 36 Health Survey (SF36). MAIN RESULTS AND THE ROLE OF CHANCE A total of 60 patients were enroled. Among the 27 patients in the conservative surgery arm, two were converted to segmental resection (7.4%). In each group, 13 presented with at least one functional problem at 24 months after surgery (48.1 versus 39.4%, OR = 0.70, 95% CI 0.22–2.21). The intention-to-treat comparison of the overall scores on KESS, GIQLI, Wexner, USP and SF36 did not reveal significant differences between the two arms. Segmental resection was associated with a significant risk of bowel stenosis. LIMITATIONS REASONS FOR CAUTION The inclusion of only large infiltrations of the rectum does not allow the extrapolation of conclusions to small nodules of <20 mm in length. The presumption of a 40% difference favourable to conservative surgery in terms of postoperative functional outcomes resulted in a lack of power to demonstrate a difference for the primary endpoint. WIDER IMPLICATIONS OF THE FINDINGS Conservative surgery is feasible in patients managed for large deep rectal endometriosis. The trial does not show a statistically significant superiority of conservative surgery for mid-term functional digestive and urinary outcomes in this specific population of women with large involvement of the rectum. There is a higher risk of rectal stenosis after segmental resection, requiring additional endoscopic or surgical procedures. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by a grant from the clinical research programme for hospitals (PHRC) in France. The authors declare no competing interests related to this study. TRIAL REGISTRATION NUMBER This study is registered with ClinicalTrials.gov, number NCT 01291576. TRIAL REGISTRATION DATE 31 January 2011. DATE OF FIRST PATIENT’S ENROLMENT 7 March 2011.

Long term efficacy of gastric electrical stimulation in intractable nausea and vomiting

BACKGROUND Although the efficacy of gastric electrical stimulation has been reported in short-term studies, there is a lack of data on the long-term improvement of nausea and vomiting by gastric electrical stimulation in patients with delayed or normal gastric emptying. METHODS Thirty-one patients were implanted at our centre for medically refractory severe and chronic nausea and/or vomiting. Patients were evaluated at baseline, 6 months then 5 years after implantation (mean follow-up 80±4 months) using a symptomatic and quality of life scores. KEY RESULTS Amongst the 31 patients, 4 were lost to follow-up, 6 explanted due to lack of improvement, and 1 patient died. Out of the 20 patients evaluated over 5 years, the quality of life score showed 27% improvement (p<0.01), including nausea (62%; p<0.01), vomiting (111%; p=0.03), satiety (158%; p<0.01), bloating (67%; p<0.01) and epigastric pain (43%; p=0.03). Over 5 years, 15/20 patients reported a 50% improvement with a global satisfaction rated at 64±6%. Therefore, 15/27 patients (56%) were improved by gastric electrical stimulation over 5 years in intention to treat. Improvement of nausea 6 months after implantation was predictive of 5-year success of gastric electrical stimulation (p=0.04). Finally, patients with delayed gastric emptying or with normal gastric emptying rate before surgery were similarly improved over 5 years (60% versus 50% respectively). CONCLUSION Gastric electrical stimulation is safe and effective in the long term in patients with medically refractory nausea and vomiting, with an efficacy over 50% beyond 5 years in intention to treat. Gastric emptying measured before implantation did not influence the response rate over 5 years.

18F-fluorodeoxyglucose positron emission tomography after definitive chemoradiotherapy in patients with oesophageal carcinoma

BACKGROUND The purpose of the study was to investigate the value of 18F-fluorodeoxyglucose-positron emission tomography performed after definitive chemoradiotherapy in patients with locally advanced oesophageal carcinoma. METHODS Forty consecutive patients underwent 18F-fluorodeoxyglucose-positron emission tomography at baseline and after chemoradiotherapy completion. Assessment of the clinical complete response to chemoradiotherapy included oesophagoscopy plus biopsies and computed tomography scan. Cox regression analysis was used to develop the univariate and multivariate models describing the association of the independent variables with survival and local control. RESULTS A clinical complete response and 18F-fluorodeoxyglucose-positron emission tomography response were present in 29 patients (72.5%) and 13 patients (32.5%), respectively. A combined response was observed in 11 patients (27.5%). During follow-up, a local failure was detected in 27.2% of patients with 18F-fluorodeoxyglucose-positron emission tomography response versus 33.3% in non-responders (p=.9). In multivariate analysis, clinical complete response (HR 5.77, p=.009) and 18F-fluorodeoxyglucose-positron emission tomography response (HR 6.27, p=.031) were identified as independent prognostic factors of overall survival. CONCLUSION In patients treated for an esophageal cancer, the present study suggested that 18F-fluorodeoxyglucose-positron emission tomography after chemoradiotherapy completion was an independent prognostic factor of overall survival without significant impact on local recurrence prediction.

Multiple nodule removal in multifocal colorectal endometriosis instead of “en bloc” large colorectal resection

Surgical management of colorectal endometriosis follows the principles of two main philosophies or approaches: radical and conservative. The radical approach has recently been recommended in multifocal colorectal endometriosis, which frequently concerns patients with rectal nodules. However, an alternative conservative management could employ selective retrieval of macroscopic colorectal deep endometriosis nodules by bowel shaving and disc excision, with preservation of the mesorectum. The conservative approach is justified by the evidence that low colorectal resection may lead to postoperative functional digestive symptoms for which management is most challenging. However, there is a lack of data in the literature specifically focusing on patients with multiple excision of deep colorectal endometriosis. No data exist about the minimal length of healthy bowel that should be conserved between two successive transversal bowel sutures, and on consecutive improvement of functional outcomes. Conversely, no evidence exists on presumed reduction of recurrence rate when young patients undergo low large colorectal resection, instead of multiple selective excisions. Further comparative studies would be welcome, among which the ENDORE randomized trial which may play a central role by comparing functional outcomes related to radical and conservative approach in deep endometriosis infiltrating the rectum.

Gastric electrical stimulation increases the discomfort threshold to gastric distension.

Introduction Gastric electrical stimulation (GES) is now considered as a new therapeutic alternative for patients with medically refractory vomiting and/or nausea, although its mechanisms of action remain poorly understood. Methods and patients Gastric discomfort threshold, measured as the gastric maximal tolerable volume (MTV) to distension, was examined before and after GES, in nine patients implanted for chronic and severe nausea and vomiting. Results GES increased gastric MTV from 522±64 ml at baseline to 628±60 ml 6 months after the start of GES (P=0.03), whereas gastric emptying remained unchanged. The increase in MTV was correlated with symptoms and quality of life at 6 months, whereas gastric emptying was not. Finally, MTV varied in a similar manner at 6 months in patients with delayed and normal gastric emptying measured before implantation. Conclusion Taken together, these data indicate that modification of gastric sensation to distension, rather than gastric emptying, is associated with symptoms’ outcome during GES.