Y.P. Le Treut

Pancreatectomy for adenocarcinoma in elderly patients: postoperative outcomes and long term results: a study of the French Surgical Association.

AIM To determine the benefit of surgery for resectable pancreatic adenocarcinomas (PAs) in elderly patients. METHODS From 2004 to 2009, 932 patients with resectable PAs underwent pancreatectomies without neoadjuvant treatment in 37 institutions. The patients were divided into three groups according to age: <70 years (control group; n = 580); 70-79 years (70s group, n = 288), and ≥ 80 years (80s group; n = 64). Preoperative, intraoperative, postoperative, and histological data were recorded to assess the postoperative course and survival. RESULTS Preoperative or intraoperative characteristics, and the histological findings were comparable in the three groups. Postoperative mortality and morbidity rates did not differ in the three groups. Adjuvant therapies were more frequently used in younger patients than in elderly patients (p < 0.01). The overall 1-year, 3-year, and 5-year survival rates of control group/70s group/80s group were 82.2%/75.7%/75.7%, 49.9%/41.8%/31%, and 38.7%/33.2%/0%, respectively (p = 0.16). The median survival of the control, 70s, and 80s groups was 24 months, 35.3 months, and 30 months, respectively. Four independent prognostic indicators were identified by multivariate analysis: venous invasion (hazard ratio (HR) = 2.12), arterial invasion (HR = 2.96), positive lymph nodes (HR = 2.25), and adjuvant treatment (HR = 0.65). CONCLUSIONS Fit elderly patients with resectable PAs should not be excluded from surgical resection of PA solely because of their real age. Moreover, elderly patients seem to obtain similar advantages from pancreatectomies than younger patients.

Prognostic value of jaundice in patients with gallbladder cancer by the AFC-GBC-2009 study group

INTRODUCTION Jaundice is frequent in patients with gallbladder cancer (GBC) and indicates advanced disease and, according to some teams, precludes routine operative exploration. The present study was designed to re-assess the prognostic value of jaundice in patients with GBC. METHODS Patients with GBC operated from 1998 to 2008 were included in a retrospective multicenter study (AFC). The main outcome measured was the prognostic value of jaundice in patients with GBC focusing on morbidity, mortality and survival. RESULTS A total of 110 of 429 patients with GBC presented with jaundice, with a median age of 66 years (range: 31-88). The resectability rate was 45% (n=50) and the postoperative mortality and morbidity rates were 16% and 62%, respectively; 71% had R0 resection and 46% had lymph node involvement. Overall 1- and 3-year survivals of the 110 jaundiced patients were 41% and 15%, respectively. For the 50 resected patients, 1- and 3-year survivals were 48% and 19%, respectively (real 5-year survivors n=4) which were significantly higher than that of the 60 non-resected patients (31%, 0%, p=0.001). Among the resected jaundiced patients, T-stage, N and M status were found to have a significant impact on survival. R0 resection did not increase the overall survival in all resected patients, but R0 increased median survival in the subgroup of N0 patients (20 months versus 6 months, p=0.01). CONCLUSION This series confirms that jaundice is a poor prognostic factor. However, the presence of jaundice does not preclude resection, especially in highly selected patients (N0).

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.

Minimal portal vein stenosis is a promising preconditioning in living donor liver transplantation in porcine model

BACKGROUND & AIMS The main hindrance in promoting living donor liver transplantation remains the morbi-mortality risk for the donor. Considering the opposed remodeling influence of portal and hepatic artery flows, our working hypothesis was to identify a lobar portal vein stenosis capable of inducing a contralateral liver mass compensatory enlargement, without the downstream ipsilateral atrophic response. METHODS Twenty-four pigs entered this study. Six of them were used to establish hemodynamic changes following a progressive left portal vein (LPV) stenosis, in blood flow, pressure and vessel diameter of the LPV, main portal vein and hepatic artery. Sixteen pigs were divided into 4 groups: sham operated animals, 20% LPV stenosis, 50% LPV stenosis, and 100% LPV stenosis. Daily liver biopsies were collected until post-operative day 5 to investigate liver regeneration and atrophy (Ki67, STAT3, LC3, and activated caspase 3) according to the degree of LPV stenosis. Finally, changes in liver volumetry after 20% LPVS were investigated. RESULTS A 20% LPV stenosis led to dilatation of the hepatic artery and a subsequent four-fold increase in hepatic arterial flow. Concomitantly, liver regeneration was triggered in the non-ligated lobe and the cell proliferation peak, 5 days after surgery, was comparable to that obtained after total LPV ligation. Moreover, 20% LPV stenosis preconditioning did not induce left liver atrophy contrary to 50 and 100% LPV stenosis. CONCLUSIONS A 20% LPV stenosis seems to be the adequate preconditioning to get the remnant liver of living donor ready to take on graft harvesting without atrophy of the future graft.