Jean-Marc Chevallier

Prognostic and Predictive Values of the Immunoscore in Patients with Rectal Cancer

Purpose: To determine whether the tumor immune infiltrate, as recently evaluated with the Immunoscore methodology, could be a useful prognostic marker in patients with rectal cancers. Experimental design: The influence of the immune infiltrate on patients outcome was investigated in patients with or without preoperative chemoradiation therapy (pCRT). The density of total (CD3+) and cytotoxic (CD8+) T lymphocytes was evaluated by immunohistochemistry and quantified by a dedicated image analysis software in surgical specimens of patients with rectal cancer (n = 111) who did not receive pCRT and in tumor biopsies performed before pCRT from additional 55 patients. The results were correlated with tumor recurrence, patients survival, and response to pCRT. Results: The densities of CD3+ and CD8+ lymphocytes and the associated Immunoscore (from I0 to I4) were significantly correlated with differences in disease-free and overall survival (HR, 1.81 and 1.72, respectively; all P < 0.005). Cox multivariate analysis supports the advantage of the Immunoscore compared with the tumor–node–metastasis (TNM) staging in predicting recurrence and survival (all P < 0.001). Lymph node ratio added information in a prognostic model (all P < 0.05). In addition, high infiltration of CD3+ and CD8+ lymphocytes in tumor biopsies was associated with downstaging of the tumor after pCRT (CD3+ cells; Fisher exact test P = 0.01). Conclusions: The Immunoscore could be a useful prognostic marker in patients with rectal cancer treated by primary surgery. The determination of the immune infiltrate in biopsies before treatment could be a valuable information for the prediction of response to pCRT. Clin Cancer Res; 20(7); 1891–9. ©2014 AACR.

Adjustable Gastric Banding in a Public University Hospital: Prospective Analysis of 400 Patients

Background: Laparoscopic application of an adjustable gastric band (LAGB) is considered the least invasive surgical option for morbid obesity. It has the advantage of being potentially reversible and can improve quality of life. Method: Between April 1997 and January 2001, 400 patients underwent LAGB. There were 352 women and 48 men with mean age 40.2 years (16-66). Preoperative mean body weight was 119 kg (85-195) and mean body mass index (BMI) was 43.8 kg/m2 (35.1-65.8). Results: Mean operative time was 116 minutes (30-380), and mean hospital stay was 4.55 days (3-42). There was no death. There were 12 conversions (3%). 40 complications required an abdominal reoperation (10%), for perforation (n=2), gastric necrosis (n=1), slippage (n=31), incisional hernia (n=2) and reconnection of the tube (n=4). We noticed 7 pulmonary complications (2 ARDS, 5 atelectasis) and 30 minor problems related to the access port. At 2 years, mean BMI had fallen from 43.8 to 32.7 kg/m2 and mean excess weight loss (EWL) was 52.7 % (12-94). Conclusion: LAGB is a very beneficial operation with an acceptable complication rate. EWL is 50% at 2 years if multidisciplinary follow-up remains assiduous. Surveillance for late anterior stomach slippage within the band is essential.

Anatomy of spontaneous splenorenal and gastrorenal venous anastomoses: Review of the literature

Portal hypertension is characterised by the development of a collateral portocaval circulation. Among these venous reroutings, some are situated posteriorly in the left subphrenic compartment. These are the spontaneous splenorenal and gastrorenal anastomoses. Their incidence is estimated at around 16%. On the one hand, there are the direct shunts, which anastomose the spelling v. to the left renal v., of an anecdotal nature, and on the other the spontaneous indirect splenorenal shunts, characterised by the presence of a complete neurovascular pedicle traversing the gastrophrenic ligament. This relates to the gastric collateral v., which is connected to the left renal v. via the inferior v. of the left crus of the diaphragm and the middle capsular v., hence the name “gastro-phreno-capsulo-renal shunt”. At an advanced stage of portal hypertension these splenorenal shunts may acquire a major caliber and behave like actual surgical shunts.

Anatomy of the common trunk of the middle and left hepatic veins: application to liver transplantation

An anastomosis between the common trunk of the middle and left hepatic veins of the receiver and the cranial portion of the inferior vena cava of the donor is one of the techniques for restoration of hepato-caval continuity in orthotopic liver transplantation. This technique avoids dissection of the retrohepatic vena cava and total caval clamping. The aim of this study was to define the feasibility of this technique by a morphologic and biometric study of the common trunk of the middle and left hepatic veins on the basis of 64 injection-corrosion hepatic specimens and 21 fresh subjects. A common trunk for the middle and left hepatic veins was present in 54 of 64 cases (84%) with a length of 3 to 17 mm. The diameter of the new ostium constructed by section 0.5 cm proximal to the junction of the middle and left hepatic veins was 23.9 ± 2.3 mm, which approximated to that of the vena cava where it traversed the diaphragm (24.4 ± 2.0 mm). These findings confirmed that restoration of hepato-caval continuity by anastomosis between the common trunk of the middle and left hepatic veins of the receiver and the cranial portion of the vena cava of the graft is possible without incongruence. This study makes no assumptions about the hemodynamic effects associated with the smallest diameter of the true ostium of the common trunk at its opening into the inferior vena cava. In this study, the morphology of the common trunk was comparable to that observed by Nakamura. Further, we propose an anatomo-clinical classification allowing evaluation of the facility of vascular control of the common trunk in terms of the number and location of the collateral veins.

Malabsorption and intestinal adaptation after one anastomosis gastric bypass compared with Roux-en-Y gastric bypass in rats

The technically easier one-anastomosis (mini) gastric bypass (MGB) is associated with similar metabolic improvements and weight loss as the Roux-en-Y gastric bypass (RYGB). However, MGB is controversial and suspected to result in greater malabsorption than RYGB. In this study, we compared macronutrient absorption and intestinal adaptation after MGB or RYGB in rats. Body weight and food intake were monitored and glucose tolerance tests were performed in rats subjected to MGB, RYGB, or sham surgery. Carbohydrate, protein, and lipid absorption was determined by fecal analyses. Intestinal remodeling was evaluated by histology and immunohistochemistry. Peptide and amino acid transporter mRNA levels were measured in the remodeled intestinal mucosa and those of anorexigenic and orexigenic peptides in the hypothalamus. The MGB and RYGB surgeries both resulted in a reduction of body weight and an improvement of glucose tolerance relative to sham rats. Hypothalamic orexigenic neuropeptide gene expression was higher in MGB rats than in RYGB or sham rats. Fecal losses of calories and proteins were greater after MGB than RYGB or sham surgery. Intestinal hyperplasia occurred after MGB and RYGB with increased jejunum diameter, higher villi, and deeper crypts than in sham rats. Peptidase and peptide or amino acid transporter genes were overexpressed in jejunal mucosa from MGB rats but not RYGB rats. In rats, MGB led to greater protein malabsorption and energy loss than RYGB. This malabsorption was not compensated by intestinal overgrowth and increased expression of peptide transporters in the jejunum.

Risk factors for airway hyperresponsiveness in severely obese women.

Obesity affects airway diameter and tidal ventilation pattern, which could perturb smooth muscle function. The objective was to assess the pathophysiology of airway hyperresponsiveness in obesity while controlling for gastro-oesophageal reflux disease. Obese women (n=118, mean±SD BMI 46.1±6.8kg/m(-2)) underwent pulmonary function testing (including tidal ventilation monitoring and methacholine challenge) and oesogastro-duodenal fibroscopy. Fifty-seven women (48%, 95% CI: 39-57%) exhibited hyperresponsiveness (dose-response slope ≥2.39% decrease/μmol) that was independently and positively correlated with predicted % FRC, Raw0.5 and negatively correlated with sigh frequency during tidal ventilation. Obese women had an increased breathing frequency but a similar sigh frequency than healthy lean women (n=30). Twenty-two obese women (19%, 95% CI: 12-26%) were classified as asthmatics (hyperresponsiveness and suggestive symptoms) without confounding effect of gastro-oesophageal reflux disease. In conclusion, in women referred for bariatric surgery, unloading of bronchial smooth muscle (reduced airway calibre and sigh frequency) is associated with hyperresponsiveness.

One-Anastomosis Gastric Bypass: Why Biliary Reflux Remains Controversial?

One-anastomosis gastric bypass is an alternative to the “gold-standard” Roux-en-Y gastric bypass. This technique appears to be safe and efficient, but controversy remains regarding the long-term theoretical risk of subsequent biliary reflux and its possible complications, such as cancer. The aim of the present narrative review was to summarize some of the current thoughts on biliary reflux. Research has established that exposure to chronic bile reflux in humans and rats (outside the “bariatric surgery” box) induce esophageal intestinal metaplasia and esophageal adenocarcinoma. Although one-anastomosis gastric bypass can theoretically induce chronic biliary reflux, the incidence of biliary reflux and risk of cancer have not been prospectively evaluated. Clarification of this controversial issue is urgently needed.

L'artère hépatique gauche, variations anatomiques et implications cliniques

But de l’etude l’artere hepatique gauche est une composante anatomique de la vascularisation arterielle hepatique qui nait de l’artere gastrique gauche et chemine dans la pars condensa du petit omentum. La chirurgie gastrique, hiatale, bariatrique et la transplantation hepatique imposent souvent la section de cette artere. Le but de notre travail a ete de faire le point sur la frequence de l’artere hepatique gauche, son role dans la vascularisation hepatique et ses implications cliniques. Materiel et methodes une revue de la litterature a comporte l’analyse des principales series anatomiques, radiologiques et chirurgicales. Resultats l’artere hepatique gauche est la persistance a l’âge adulte de la branche arterielle vascularisant l’ebauche hepatique embryonnaire gauche. Elle vascularise un territoire variable du foie allant d’une partie du lobe gauche a la totalite du foie dans 1 % des cas. Sa frequence varie de 14 % a 27 % dans les series anatomiques, de 12 % a 20 % dans les etudes arteriographiques et de 12 % a 24 % dans les series de transplantation hepatiques. Des etudes cœlioscopiques ont rapporte une frequence plus elevee, allant de 18 % a 34 %. La difference de sensibilite des methodes de detection explique la difference des frequences observees. Conclusions la frequence de l’artere hepatique gauche est de 12 % a 24 %. Elle vascularise le plus souvent le lobe gauche, mais dans 1 % des cas la totalite du foie. Une parfaite connaissance de ces variations est donc necessaire au cours de la chirurgie gastrique, hiatale, bariatrique et hepatique.

Anatomic basis of mesenteric elongation for ileo-anal anastomosis with J-shaped reservoir: comparison of two techniques of vascular section.

SummaryTotal proctocolectomy followed by ileo-anal anastomosis with a reservoir is the operation of choice for the treatment of familial adenomatous polyposis and of certain forms of hemorrhagic proctocolitis. Vascular section is sometimes necessary to enable the extremity of the reservoir to reach the anal sphincter without traction. The aim of this study was to compare the gain in length obtained by two different techniques of vascular section and to assess in terms of the vascular anatomy of the last small intestinal loop which technique best preserved the vascularisation of the reservoir as a whole. Twenty-two fresh cadavers had an ileal J-shaped reservoir of 18 cm fashioned from the last loop of small intestinal loop after section of the root of the mesentery. The gains in length so obtained were measured after section of the ileocolic a. at its origin (group A) or section between the two vascular arches of the last small intestinal loop (group B); the superior mesenteric vessels were then injected with colored resin. The gain in length obtained by these two methods was identical (2.3 ± 1.1 cm for group A as against 2.18 ± 0.9 cm for group B), but only if the section of the ileocolic a. was accompanied by section of the mesenteric peritoneum up to the vascular arch formed by the anastomosis between the terminal branch of the superior mesenteric a. and the ileocolic a. The constancy of this anastomosis always allowed section of the ileocolic a. while preserving good vascular distribution to the entirety of the reservoir. Section between the two arches was difficult when the distance separating them was small.RésuméLa coloproctectomie totale suivie d’anastomose iléo-anale avec réservoir est l’intervention de choix pour le traitement de la polypöse adénoma-teuse familiale et de certaines formes de recto-colite hémorragique. Des sections vasculaires sont parfois nécessaires pour que l’extrémité du réservoir atteigne sans traction le sphincter anal. Le but de ce travail était de comparer le gain de longueur obtenu par deux techniques différentes de section vasculaire et d’évaluer en fonction de l’anatomie vasculaire de la dernière anse grêle, quelle technique préservait le mieux la vascularisation de la totalité du réservoir. Vingt deux sujets frais ont eu un réservoir iléal en J de 18 cm confectionnée au dépens de la dernière anse grêle après section de la racine du mésentère. Les gains de longueur obtenus ont été mesurés soit après section de l’a. iléo-colique à son origine (groupe A), soit après section entre les 2 arcades vasculaires de la dernière anse grêle (groupe B), puis les vaisseaux mésentériques supérieurs ont été injectés par de la résine colorée, le gain de longueur obtenu par ces deux méthodes est identique (2,3 ± 1,1 cm pour le groupe 1 vs 2,18 ± 0,9 cm pour le groupe 2) uniquement si la section de l’a. iléo-colique s’accompagne d’une section du péritoine mésentérique jusqu’à l’arcade vasculaire formée par l’anastomose entre la branche terminale de l’a. mésentérique supérieure et l’a. iléo-colique. La constance de cette anastomose permet toujours la section de l’a. iléo-colique tout en conservant une bonne distribution vasculaire à la totalité du réservoir. La section entre les deux arcades est difficile si la distance qui les sépare est petite.

Histological basis of the liver hanging maneuver

BackgroundLiver hanging maneuver (LHM) consists in passing a tape between the retrohepatic inferior vena cava (RHIVC) and the liver to perform various kinds of hepatectomies. LHM is a well-known procedure but its histological basis remains poorly documented.MethodsTen anatomical specimens comprising RHIVC, and surrounding hepatic parenchyma were studied after conventional staining and immunohistochemistry with specific antibody for alpha smooth muscle actin.ResultsRHIVC wall structure consists of a thick muscular layer of longitudinal smooth muscle fibers and a peripheral loose connective tissue without smooth muscle fibers adherent to the liver parenchyma. This loose connective tissue between the liver and the RHIVC is the avascular plane for the passage of the clamp during LHM.ConclusionThe histological structure of the RHIVC does not seem to have any special hemostatic property. The low bleeding rate during LHM can be only explained by the very low density of RHIVC afferent veins.