V. Moutardier

Neoadjuvant chemoradiation and pancreaticoduodenectomy for initially locally advanced head pancreatic adenocarcinoma.

BACKGROUND The most accepted treatment for locally advanced pancreatic adenocarcinoma (LAPA) is chemoradiotherapy (CRT). We sought to determine the benefit of pancreaticoduodenectomy (PD) in patients with LAPA initially treated by neoadjuvant CRT. METHODS From January 1996 to December 2006, 64 patients with LAPA (borderline, n=49; unresectable, n=15) received 5-fluorouracil-cisplatin-based CRT. Of the 64 patients, 47 had progressive disease at restaging. Laparotomy was performed for 17 patients, and PD was performed in 9 patients (resected group). Fifty-five patients had CRT followed by gemcitabine-based chemotherapy (unresected group). RESULTS The median survival and overall 5 years survival duration of all 64 patients were 14 months and 12%, respectively. The mean delay between diagnosis and surgical resection was 5.5 months. Mortality and morbidity from PD were 0% and 33%, respectively. The median survival of the resected group vs. the unresected group was 24 months vs. 13 months. Three specimens presented a major pathological response at histological examination. No involved margins were found and positive lymph nodes were found in one patient. Resected patients developed distant metastases. CONCLUSIONS PD after CRT was safe and resected patients had interesting survival rates. However, resected patients developed metastatic disease and new neoadjuvant regimens are needed to improve the survival of these patients.

Aggressive multimodal therapy of sporadic malignant insulinoma can improve survival: a retrospective 35-year study of 12 patients.

AIM Sporadic malignant insulinoma (SMI) is a rare disease, and the consequent paucity of data in the literature and the development of aggressive treatments for liver metastases have led us to retrospectively analyze a series of 12 cases of SMI. METHODS Every patient presenting with SMI, according to the WHO 2004 histopathology criteria, between 1970 and June 2005 in Marseille was included in the study. Patients with multiple endocrine neoplasia type 1 (MEN-1) and tumours of uncertain malignant potential were excluded. RESULTS The ratio of male/female was 4/8, and mean age at diagnosis was 52.5 years. A 48-h fasting test in 10 patients was conclusive in nine, after a mean duration of 12 h 45 min. SMI size ranged from 7-120 mm (mean 30.3mm). Six patients had liver metastases and one had isolated lymph-node invasion. Surgery was performed in 12 patients. Five persisting diseases (mean follow-up of 1.8 years) required other treatments (chemoembolization, radiofrequency thermoablation [RFTA], liver transplantation); one patient relapsed 8.5 years after surgery; six were still in complete remission (mean follow-up of 5.8 years), and one patient had died by the time of the 24-month follow-up. CONCLUSION Aggressive sequential multimodal therapy can prolong the survival of patients with SMI even in the presence of liver metastases.

Conservative surgery vs. duodeneopancreatectomy in primary duodenal gastrointestinal stromal tumors (GIST): a retrospective review of 114 patients from the French sarcoma group (FSG).

BACKGROUND Duodenal GISTs represent 3-5% of all GISTs with limited understanding of patient outcomes. We conducted a retrospective analysis of primary localized duodenal GISTs. METHODS Patients were identified via a survey from 16 FSG centers (n = 105), and a group of 9 patients enrolled in the BFR14 trial. Data were collected from the original database and patient files, in agreement with French legislation. RESULTS 114 patients were included, with a median age of 57. Tumors originated mainly in D2 (33%), or D3 (24%), with a median size of 5 cm. 109 patients had resection of the primary tumor; with a Local Resection (LR, n = 82), a pancreaticoduodenectomy (PD, n = 23), and data were missing for 4 patients. Resections were R0 (n = 87, 79%), R1 (n = 8, 7%), R2 (n = 6). Tumor characteristics were: KIT+ (n = 104), CD34+ (n = 58). Miettinen risk was low (n = 43), and high (n = 52). Imatinib was administered preoperatively (n = 11) and post-operatively (n = 20). With a median follow-up of 36 months (2-250), 98 patients are alive, and 33 relapsed. The 5-year OS and EFS rates are 86.5% and 54.5%. EFS was similar for patients in the LR and the PD groups (P > 0.05). In multivariate analysis, ECOG PS, and CD34 expression are independent prognostic factors on OS. Miettinen risk and spindle cell type are independent predictive factors for relapse. CONCLUSIONS Patients with resected duodenal GIST have a reasonably favorable prognosis. This study favors a preservation of pancreas when there are no anatomical constraints. LR exhibit similar survival and smaller morbidity then PD.

Fatal bowel infarction due to aspergillosis after chemotherapy.

Prevalence of invasive fungal infections has increased over the last 20 years. One of the main difficulties encountered in patients carrying these pathogens is to obtain a definitive diagnosis. Intestinal aspergillosis (IA) is an extremely severe complication of hematologic malignancies during chemotherapy induction. To our knowledge despite specific treatment, IA remains constantly lethal in case of bowel infarction. This complication have to be taken into account in high-risk patients particularly in those with candida or aspergillus infection, which account for the majority of fungal infections. We report a patient with acute myelogenous leukaemia affected by a favourable subtype of acute myelogenous leukaemia (AML-M1) who, despite treatment of aspergillus sinusitis, succumbed to fatal IA after effective induction treatment. A 52-year-old man with a history of (AML-1) received induction chemotherapy using daunorubicine and cytarabine in September 2000. Over two weeks, he developed abdominal pain with diarrhea, fever and melena. No evidence of a fungal infection was found and aspergillus antigen was negative. He underwent a normal upper digestive tract endoscopy and coloscopy. He remained febrile despite treatment with amphotericin B and ancotil. Subsequently he developed an acute abdomen. A CT-scan showed a massive ascites with pneumoperitoneum and signs of bowel infarction. Laparotomy revealed small bowel necrosis. Pathology revealed infiltrate by a high density of Aspergillus hyphae (Fig. 1). He subsequently died. Diagnosis of IA is difficult and in our case blood and sputum cultures as well as serological test were negatives and allow early anti-fungal treatment. Careful examination or risk factors, including neutropenia, nature of the underlying haematology disease, corticoid therapy, GVHD, colonisation, may help to define the diagnosis.

Risques liés au tabagisme en chirurgie générale et digestive

Peri-operative smoking history is an important risk factor, which is often under-appreciated by surgeons. In the first place, tobacco use predisposes patients to specific pathologies, which may require surgical intervention. Secondarily, smoking has been shown to increase surgical risks of mortality, morbidity and length of hospital stay. Of particular importance in general surgery is the increased risk of anastomotic leak with fistula formation, of deep infections, and of abdominal wall complications (infection and ventral hernia). If the patient can stop smoking prior to surgery, there is a concomitant decrease in post-operative complications. Surgeons should be familiar with the pharmacologic and behavioral interventions, which may help the patient with smoking cessation and should not hesitate to defer elective surgery for four to eight weeks so that the patient may have the full benefit of smoking cessation.

‘Peripheric’ pancreatic cysts: performance of CT scan, MRI and endoscopy according to final pathological examination

OBJECTIVE To assess the accuracy of pre-operative staging in patients with peripheral pancreatic cystic neoplasms (pPCNs). METHODS From 2005 to 2011, 148 patients underwent a pancreatectomy for pPCNs. The pre-operative examination methods of computed tomography (CT), magnetic resonance imaging (MRI), endoscopic ultrasonography (EUS) were compared for their ability to predict the suggested diagnosis accurately, and the definitive diagnosis was affirmed by pathological examination. RESULTS A mural nodule was detected in 34 patients (23%): only 1 patient (3%) had an invasive pPCN at the final histological examination. A biopsy was performed in 79 patients (53%) during EUS: in 55 patients (70%), the biopsy could not conclude a diagnosis; the biopsy provided the correct and wrong diagnosis in 19 patients (24%) and 5 patients (6%), respectively. A correct diagnosis was affirmed by CT, EUS and pancreatic MRI in 60 (41%), 103 (74%) and 80 (86%) patients (when comparing EUS and MRI; P = 0.03), respectively. The positive predictive values (PPVs) of CT, EUS and MRI were 70%, 75% and 87%, respectively. CONCLUSIONS Pancreatic MRI appears to be the most appropriate examination to diagnose pPCNs accurately. EUS alone had a poor PPV. Mural nodules in a PCN should not be considered an indisputable sign of pPCN invasiveness.

Late postpancreatectomy hemorrhage: Predictive factors of morbidity and mortality after percutaneous endovascular treatment

PURPOSE The objective of this study was to evaluate the effectiveness of endovascular treatment in patients presenting with late hemorrhage after pancreatectomy (LPPH). MATERIAL AND METHOD Between 2008 and 2012, 53 percutaneous arterial procedures were performed in 42 patients with LPPH. There were 27 men and 15 women (mean age, 61.8 years±14.5 [SD]; range: 19-81 years). Clinical and technical success along with frequency of complications associated with the use of different endovascular techniques in patients with and without arterial anatomical variation were assessed. RESULTS Clinical success was observed in 35/42 patients (85%). The technical success was 37.5% in patients with anatomical variation versus 82.8% for those with modal anatomy (P=0.003). Repeat bleeding (P=0.029), complications (P=0.013) and mortality (P=0.045) were more frequent in patients with variation of celiac artery than in those with modal anatomy. For hepatic and gastroduodenal artery stump bleeding, the rate of complications was higher (60%) in the group treated by hepatic artery embolization (P=0.028) by comparison with gastroduodenal artery stump selective embolisations or treatments by covered stent. A significant difference in mortality rate was found between patients with anatomical variations of celiac artery (36.4%) and those with normal anatomy (6.5%) (P=0.032). CONCLUSION Percutaneous endovascular treatment is effective in patients presenting with LPPH. The presence of an anatomical variation of the celiac artery increases the rate of complications and mortality in patients with LPPH.

Fusion spléno-gonadique associée à une cryptorchidie intra-abdominale chez l'adulte

a fusion spléno-gonadique est une malformation congénitale rare correspondant à une fusion entre le parenchyme splénique et le testicule. Deux formes sont décrites : la forme continue lorsqu’il existe un cordon fibreux ou une continuité tissulaire entre la rate et le testicule et la forme discontinue quand la fusion des deux tissus est totalement séparée de la rate. Le diagnostic est généralement fait à l’âge pédiatrique devant une masse scrotale ou, plus rarement, dans le cadre de l’exploration d’une cryptorchidie. Nous rapportons un cas de fusion et cryptorchidie intra-abdominale chez un adulte de découverte fortuite sur un examen scanner.

Risk factors of exocrine and endocrine pancreatic insufficiency after pancreatic resection: A multi-center prospective study

Management of functional consequences after pancreatic resection has become a new therapeutic challenge. The goal of our study is to evaluate the risk factors for exocrine (ExoPI) and endocrine (EndoPI) pancreatic insufficiency after pancreatic surgery and to establish a predictive model for their onset. PATIENTS AND METHODS Between January 1, 2014 and June 19, 2015, 91 consecutive patients undergoing pancreatoduodenectomy (PD) or left pancreatectomy (LP) (72% and 28%, respectively) were followed prospectively. ExoPI was defined as fecal elastase content<200μg per gram of feces while EndoPI was defined as fasting glucose>126mg/dL or aggravation of preexisting diabetes. The volume of residual pancreas was measured according to the same principles as liver volumetry. RESULTS The ExoPI and EndoPI rates at 6 months were 75.9% and 30.8%, respectively. The rate of ExoPI after PD was statistically significantly higher than after LP (98% vs. 21%; P<0.001), while the rate of EndoPI was lower after PD vs. LP, but this difference did not reach statistical significance (28% vs. 38.5%; P=0.412). There was no statistically significant difference in ExoPI found between pancreatico-gastrostomy (PG) and pancreatico-jejunostomy (PJ) (100% vs. 98%; P=1.000). Remnant pancreatic volume less than 39.5% was predictive of ExoPI. CONCLUSION ExoPI occurs quasi-systematically after PD irrespective of the reconstruction scheme. The rate of EndoPI did not differ between PD and LP.

Resectable pancreatic head adenocarcinoma: Is R0 resection an illusion? Genetic evaluation of venous resection margin affirmed unrecognized disease

PURPOSE To assess the K-ras gene mutation in the histologically negative venous margin of a pancreaticoduodenectomy (PD) specimen and its impact on survival. METHOD From 2007 to 2010, 22 patients underwent R0 PD for resecable pancreatic adenocarcinoma. All specimens were stained and the portal vein (PV) bed was identified by blue ink; a 2mm3 sample (including the blue ink) was cut from a microscopic free-tumor block. DNA was extracted and assessed by quantitative real time polymerase chain reaction to detect the K-ras gene mutation. Twelve specimens (55%) (kras+ group) were identified with a K-ras mutation in the venous margin resection, and 10 specimens (kras- group) did not have K-ras mutation detected in the venous margin resection. RESULTS The two groups were comparable. Overall 3years survival of patients of kras+ group versus patients of kras- group was 0 and 17% (P=0.03), respectively. Median survival time of patients of kras+ group versus patients of kras- group was 16months vs 25months (P=0.04; 95% confidence interval [1,11-1,88]), respectively. CONCLUSION Genetic evaluation of venous resection margin affirmed unrecognized disease with strong impact on survival in more than 50% of patients with histologically R0 resection.