Does portal vein anatomy influence intrahepatic distribution of metastases from colorectal cancer?

BACKGROUND: Other than location of the primary colorectal cancer (CRC), a few factors are known to influence the intrahepatic distribution of colorectal cancer liver metastases (CRLM). We aimed to assess whether the anatomy of the portal vein (PV) could influence the intrahepatic distribution of CRLM. PATIENTS AND METHODS: Patients with CRLM diagnosed between January 2018 and December 2022 at two tertiary centers were included and imaging was reviewed by two radiologists independently. Intra-operator concordance was assessed according to the intraclass correlation coefficient (ICC). The influence of the diameter, angulation of the PV branches and their variations on the number and distribution of CRLM were compared using Mann-Whitney, Kruskal-Wallis, Pearson's Chi-square and Spearman's correlation tests. RESULTS: Two hundred patients were included. ICC was high (> 0.90, P < 0.001). Intrahepatic CRLM distribution was right-liver, left-liver unilateral and bilateral in 66 (33%), 24 (12%) and 110 patients (55%), respectively. Median number of CRLM was 3 (1-7). Type 1, 2 and 3 portal vein variations were observed in 156 (78%), 19 (9.5%) and 25 (12%) patients, respectively. CRLM unilateral or bilateral distribution was not influenced by PV anatomical variations (P = 0.13), diameter of the right (P = 0.90) or left (P = 0.50) PV branches, angulation of the right (P = 0.20) or left (P = 0.80) PV branches and was independent from primary tumor localisation (P = 0.60). No correlations were found between CRLM number and diameter (R: 0.093, P = 0.10) or angulation of the PV branches (R: 0.012, P = 0.83). CONCLUSIONS: PV anatomy does not seem to influence the distribution and number of CRLM.

Mini-Laparoscopic Cholecystectomy During the Late Second and Third Trimesters of Pregnancy.

BACKGROUND: Mini-laparoscopic cholecystectomy (MLC) reduces abdominal wall injury and has the advantage of not altering the surgical principles of conventional laparoscopic cholecystectomy. Our team recently decided to extend the indications for mini-laparoscopy to pregnant women requiring cholecystectomy in the late second and third trimesters when significant uterine height is a potential difficulty. METHODS: From January 2022, all patients who underwent MLC after five months of pregnancy were included in the analysis. Operative, postoperative, and perinatal outcomes were retrospectively collected. RESULTS: Ten patients underwent MLC between 24 and 32 weeks of gestation. The mean operative time was 73 ± 24 minutes. Only one minor intraoperative complication was observed. The mean postoperative pain, quality of life, and cosmetic satisfaction at the first postoperative visit were 1.8 ± 0.9, 9.1 ± 0.8, and 9.5 ± 0.8, respectively. Finally, all patients had an uncomplicated vaginal delivery. No preterm delivery or fetal loss occurred. CONCLUSIONS: These preliminary results suggest that the mini-laparoscopy could be used safely in selected pregnant women requiring cholecystectomy even after five months of gestation. By preserving the abdominal wall as much as possible, MLC may be of particular interest in this particular case, when the patient's abdominal wall could potentially be subjected to severe secondary stress in the event of vaginal delivery.

Somatic Molecular Heterogeneity in Bilateral Macronodular Adrenocortical Disease (BMAD) Differs Among the Pathological Subgroups.

Bilateral macronodular adrenocortical disease (BMAD) is an uncommon cause of Cushing's syndrome leading to bilateral macronodules. Isolated BMAD has been classified into three molecular groups: patients with ARMC5 alteration, KDM1A alteration, and patients without known genetic cause. The aim of this study was to identify by NGS, in a cohort of 26 patients with BMAD, the somatic alterations acquired in different nodules after macrodissection from patients with germline ARMC5 or KDM1A alterations and to analyze potential somatic alterations in a panel of five other genes involved in adrenal pathology (GNAS, PDE8B, PDE11A, PRKAR1A, and PRKACA). Twenty-three patients (7 ARMC5, 3 KDM1A, and 13 BMAD with unknown genetic cause) were analyzable. Somatic ARMC5 or KDM1A events were exclusively observed in patients with germline ARMC5 and KDM1A alterations, respectively. Six out of 7 ARMC5 patients have a high heterogeneity in identified somatic events, whereas one ARMC5 and all KDM1A patients show a loss of heterozygosity (LOH) in all nodules. Except for passenger alterations of GNAS, no genetic alteration susceptible to causing the disease was detected in the BMAD with unknown genetic cause. Our study reinforces our knowledge of the somatic genetic heterogeneity of ARMC5 and the somatic homogeneity of KDM1A. It reveals the absence of purely somatic events in these two genes and provides a new tool for detecting KDM1A alterations by FISH 1p36/1q25.

Stenosis of the colorectal anastomosis after surgery for diverticulitis: A national retrospective cohort study.

AIM: The aim of this work was to investigate the association between early postoperative anastomotic leakage or pelvic abscess (AL/PA) and symptomatic anastomotic stenosis (SAS) in patients after surgery for left colonic diverticulitis. METHOD: This is a retrospective study based on a national cohort of diverticulitis surgery patients carried out by the Association Française de Chirurgie. The assessment was performed using path analyses. The database included 7053 patients operated on for colonic diverticulitis, with surgery performed electively or in an emergency, by open access or laparoscopically. Patients were excluded from the study analysis where there was (i) right-sided diverticulitis (the initial database included all consecutive patients operated on for colonic diverticulitis), (ii) no anastomosis was performed during the first procedure or (iii) missing information about stenosis, postoperative abscess or anastomotic leakage. RESULTS: Of the 4441 patients who were included in the final analysis, AL/PA occurred in 327 (4.6%) and SAS occurred in 82 (1.8%). AL/PA was a significant independent factor associated with a risk for occurrence of SAS (OR = 3.41, 95% CI = 1.75-6.66), as was the case for diverting stoma for ≥100 days (OR = 2.77, 95% CI = 1.32-5.82), while central vessel ligation proximal to the inferior mesenteric artery was associated with a reduced risk (OR = 0.41; 95% CI = 0.19-0.88). Diverting stoma created for <100 days or ≥100 days was also a factor associated with a risk for AL/PA (OR = 3.08, 95% CI = 2-4.75 and OR = 12.95, 95% CI = 9.11-18.50). Interestingly, no significant association between radiological drainage or surgical management of AL/PA and SAS could be highlighted. CONCLUSION: AL/PA was an independent factor associated with the risk for SAS. The treatment of AL/PA was not associated with the occurrence of anastomotic stenosis. Diverting stoma was associated with an increased risk of both AL/PA and SAS, especially if it was left for ≥100 days. Physicians must be aware of this information in order to decide on the best course of action when creating a stoma during elective or emergency surgery.

Evolution of minimally invasive liver surgery in France over the last decade.

BACKGROUND: Despite evidence of benefits on postoperative outcomes, minimally invasive liver surgery (MILS) had a very low diffusion up to 2014, and recent evolution is unknown. Our aim was to analyze the recent diffusion and adoption of MILS and compare the trends in indications, extent of resection, and institutional practice with open liver surgery (OLS). METHODS: We analyzed the French nationwide, exhaustive cohort of all patients undergoing a liver resection in France between January 1, 2013 and December 31, 2022. Average annual percentage changes (AAPC) in the incidence of MILS and OLS were compared using mixed-effects log-linear regression models. Time trends were analyzed in terms of extent of resection, indication, and institutional practice. RESULTS: MILS represented 25.2% of 74,671 liver resections and year incidence doubled from 16.5% in 2013 to 35.4% in 2022. The highest AAPC were observed among major liver resections [+ 22.2% (19.5; 24.9) per year], primary [+ 10.2% (8.5; 12.0) per year], and secondary malignant tumors [+ 9.9% (8.2; 11.6) per year]. The highest increase in MILS was observed in university hospitals [+ 14.7% (7.7; 22.2) per year] performing 48.8% of MILS and in very high-volume (> 150 procedures/year) hospitals [+ 12.1% (9.0; 15.3) per year] performing 19.7% of MILS. OLS AAPC decreased for all indications and institutions and accelerated over time from - 1.8% (- 3.9; - 0.3) per year in 2013-2018 to - 5.9% (- 7.9; - 3.9) per year in 2018-2022 (p = 0.013). CONCLUSIONS: This is the first reported trend reversal between MILS and OLS. MILS has considerably increased at a national scale, crossing the 20% tipping point of adoption rate as defined by the IDEAL framework.

Risk factors for emergency surgery for diverticulitis: A retrospective multicentric French study at 41 hospitals.

BACKGROUND: The observed increase in the incidence of complicated diverticulitis may lead to the performance of more emergency surgeries. This study aimed to assess the rate and risk factors of emergency surgery for sigmoid diverticulitis. METHOD: The primary outcomes were the rate of emergency surgery for sigmoid diverticulitis and its associated risk factors. The urgent or elective nature of the surgical intervention was provided by the surgeon and in accordance with the indication for surgical treatment. A mixed logistic regression with a random intercept after multiple imputations by the chained equation was performed to consider the influence of missing data on the results. RESULTS: Between 2010 and 2021, 6,867 patients underwent surgery for sigmoid diverticulitis in the participating centers, of which one-third (n = 2317) were emergency cases. In multivariate regression analysis with multiple imputation by chained equation, increasing age, body mass index <18.5 kg/m2, neurologic and pulmonary comorbidities, use of anticoagulant drugs, immunocompromised status, and first attack of sigmoid diverticulitis were independent risk factors for emergency surgery. The likelihood of emergency surgery was significantly more frequent after national guidelines, which were implemented in 2017, only in patients with a history of sigmoid diverticulitis attacks. CONCLUSION: The present study highlights a high rate (33%) of emergency surgery for sigmoid diverticulitis in France, which was significantly associated with patient features and the first attack of diverticulitis.

Differentiation between adrenocortical carcinoma and lipid-poor adrenal adenoma using a multiparametric MRI-based diagnostic algorithm.

PURPOSE: The purpose of this study was to evaluate the capabilities of multiparametric magnetic resonance imaging (MRI) in differentiating between lipid-poor adrenal adenoma (LPAA) and adrenocortical carcinoma (ACC). MATERIALS AND METHODS: Patients of two centers who underwent surgical resection of LPAA or ACC after multiparametric MRI were retrospectively included. A training cohort was used to build a diagnostic algorithm obtained through recursive partitioning based on multiparametric MRI variables, including apparent diffusion coefficient and chemical shift signal ratio (i.e., tumor signal intensity index). The diagnostic performances of the multiparametric MRI-based algorithm were evaluated using a validation cohort, alone first and then in association with adrenal tumor size using a cut-off of 4 cm. Performances of the diagnostic algorithm for the diagnosis of ACC vs. LPAA were calculated using pathology as the reference standard. RESULTS: Fifty-four patients (27 with LPAA and 27 with ACC; 37 women; mean age, 48.5 ± 13.3 [standard deviation (SD)] years) were used as the training cohort and 61 patients (24 with LPAA and 37 with ACC; 47 women; mean age, 49 ± 11.7 [SD] years) were used as the validation cohort. In the validation cohort, the diagnostic algorithm yielded best accuracy for the diagnosis of ACC vs. LPAA (75%; 46/61; 95% CI: 55-88) when used without lesion size. Best sensitivity was obtained with the association of the diagnostic algorithm with tumor size (96%; 23/24; 95% CI: 80-99). Best specificity was obtained with the diagnostic algorithm used alone (76%; 28/37; 95% CI: 60-87). CONCLUSION: A multiparametric MRI-based diagnostic algorithm that includes apparent diffusion coefficient and tumor signal intensity index helps discriminate between ACC and LPAA with high degrees of specificity and accuracy. The association of the multiparametric MRI-based diagnostic algorithm with adrenal lesion size helps maximize the sensitivity of multiparametric MRI for the diagnosis of ACC.

Publication Fate of Research Works Achieved During Master's Degree in Surgical Science in a French Survey.

The aim of this study was to assess the publication fate of research projects performed during the research year by students enrolled in a Master's degree (MSc) of surgical science and to identify factors associated with subsequent publication. An anonymous online survey of 35 questions was sent to students enrolled in MSc of surgical science between 2013 and 2020. The questionnaire included student's characteristics, topic, and supervision of the research projects developed during the research year and dissemination of the research work. Data regarding publication was collected using PubMed database. Factors associated with publication were identified by univariate analysis. Among 361 students, 26% completed the survey. Among respondents, the publication rate of research projects was 53.7%. The median time interval between the end of the research year and the date of publication was 2 (1-3) years. The student was listed as a first author in 70.6% of publications. Factors associated with publication of the research work completed during the research year were student's previous publications (P = 0.041) and presentation of the research work in academic conferences (P = 0.005). The most mentioned cause for non-publication was the absence of completion of the research work. Among respondents, the publication rate of research works performed during the MSc was high, which emphasizes the quality of the work carried out by the students and their involvement. Significant efforts must be undertaken to encourage the enrollment of residents in scientific research. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01973-y.

Clinical care pathways of patients with biliary tract cancer: A French nationwide longitudinal cohort study.

BACKGROUND: Although the incidence of BTC is raising, national healthcare strategies to improve care lack. We aimed to explore patient clinical care pathways and strategies to improve biliary tract cancer (BTC) care. METHODS: We analysed the French National Healthcare database of all BTC inpatients between January 1, 2017 and December 31, 2021. Multinomial logistic regression adjusted odds ratios (aOR) were used to identify healthcare organisation factors that influenced access to curative care both overall and in a longitudinal sensibility analysis using optimal matching and hierarchical ascending classification to detect a subgroup of curative-care patients with a high survival over a two-year period. RESULTS: A total of 19,825 new BTC patients and three clinical care pathways (CCP) were identified: 'Palliative care' (PC-CCP), 'Non-curative Care' (NCC-CCP) and 'Curative Care' (CC-CCP) involving 7669 (38.7%), 7721 (38.9%) and 4435 (22.4%) patients respectively. Out of 1200 centers involved in BTC treatment, 84%, 11% and 5% were of low- (<15 patients/year), medium- (15-30 patients/year) and high-volume (>30 patients/year) respectively. Among patient, tumor and hospital factors, BTC management in academic (aOR: 2.32; 95%CI: 1.98-2.71), private (2.51; 2.22-2.83), semi-private (2.25; 1.91-2.65) and in high- (2.09; 1.81-2.42) or medium-volume (1.49; 1.33-1.68) centers increased probability to CC-CCP. These results were maintained in a longitudinal cluster of 2363 (53%) CC-CCP patients presenting a higher two-year survival compared with the rest [96.4% (95.1; 97.6) vs. 38.8% (36.3; 41.4), log-rank p < 0.001]. CONCLUSIONS: Among factors subject to healthcare policy improvement, the volume and type of centers managing BTC strongly influenced access to curative care.

Factors of oncological failure in two stage hepatectomy for colorectal liver metastases.

BACKGROUND: Two-stage hepatectomy (TSH) has increased the chance of surgical resections for bilobar colorectal liver metastases (CRLM). Nevertheless, drop-out between stages and early recurrence rates raise the question of surgical futility in some situations. This study aimed to identify factors of TSH oncological failure. METHODS: Patients with bilobar CRLM eligible for TSH in three tertiary centers between 2010 and 2021 were included, and divided in Failure and Success groups. Oncological failure was defined as failure of the second stage hepatectomy for tumor progression or recurrence within 6 months after resection. RESULTS: Among 95 patients, 18 (18.9%) had hepatic progression between the two stages, and 7 (7.4%) failed to complete the second stage hepatectomy. After TSH, 31 (32.6%) patients experienced early recurrence. Overall, 38 (40.0%) patients experienced oncological failure (Failure group). The Failure group had lower median DFS (3 vs. 32 months, p < 0.001) and median OS (29 vs. 70 months, p = 0.045) than the Success group. On multivariable analysis, progression between the two stages in the future liver remnant (OR = 15.0 (3.22-113.0), p = 0.002), and maximal tumor size ≥40 mm in the future liver remnant (OR = 13.1 (2.12-117.0), p = 0.009) were independent factors of oncological failure. CONCLUSION: Recurrence between the two stages and maximal tumor size ≥40 mm in the future liver remnant were associated with TSH failure for patients with bilobar CRLM.

Study of Risk Factors for Readmission After Pancreatectomy for Cancer: Analysis of Nationwide Cohort.

OBJECTIVE: To identify the factors associated with readmission after pancreatectomy for cancer and to assess their impact on the 1-year mortality in a French multicentric population. BACKGROUND: Pancreatectomy is a complex procedure with high morbidity that increases the length of hospital stay and jeopardizes survival. Hospital readmissions lead to increased health system costs, making this a topic of great interest. METHODS: Data collected from patients who underwent pancreatectomy for cancer between 2011 and 2019 were extracted from a French national medico-administrative database. A descriptive analysis was conducted to evaluate the association of baseline variables, including age, sex, liver-related comorbidities, Charlson Comorbidity Index, tumor localization, and use of neoadjuvant therapy, along with hospital type and volume, with readmission status. Centers were divided into low and high volumes according to the cutoff of 26 cases/year. Logistic regression models were developed to determine whether the identified bivariate associations persisted after adjusting for the patient characteristics. The mortality rates during readmission and at 1 year postoperatively were also determined. RESULTS: Of 22,935 patients who underwent pancreatectomy, 9129 (39.3%) were readmitted within 6 months. Readmission rates by year did not vary over the study period, and mean readmissions occurred within 20 days after discharge. Multivariate analysis showed that male sex [odds ratio (OR) = 1.12], age >70 years (OR = 1.16), comorbidities (OR = 1.21), distal pancreatectomy (OR = 1.11), and major postoperative complications (OR = 1.37) were predictors of readmission. Interestingly, readmission and surgery in low-volume centers increased the risk of death at 1 year by a factor of 2.15 [(2.01-2.31), P < 0.001] and 1.31 [(1.17-1.47), P < 0.001], respectively. CONCLUSIONS: Readmission after pancreatectomy for cancer is high with an increased rate of 1-year mortality.

Impact of the first wave of COVID-19 epidemy on the surgical management of sigmoid diverticular disease in France: National French retrospective study.

OBJECTIVE: To analyze the surgical management of sigmoid diverticular disease (SDD) before, during, and after the first containment rules (CR) for the first wave of COVID-19. METHODS: From the French Surgical Association multicenter series, this study included all patients operated on between January 2018 and September 2021. Three groups were compared: A (before CR period: 01/01/18-03/16/20), B (CR period: 03/17/20-05/03/20), and C (post CR period: 05/04/20-09/30/21). RESULTS: A total of 1965 patients (A n = 1517, B n = 52, C n = 396) were included. The A group had significantly more previous SDD compared to the two other groups (p = 0.007), especially complicated (p = 0.0004). The rate of peritonitis was significantly higher in the B (46.1%) and C (38.4%) groups compared to the A group (31.7%) (p = 0.034 and p = 0.014). As regards surgical treatment, Hartmann's procedure was more often performed in the B group (44.2%, vs A 25.5% and C 26.8%, p = 0.01). Mortality at 90 days was significantly higher in the B group (9.6%, vs A 4% and C 6.3%, p = 0.034). This difference was also significant between the A and B groups (p = 0.048), as well as between the A and C groups (p = 0.05). There was no significant difference between the three groups in terms of postoperative morbidity. CONCLUSION: This study shows that the management of SDD was impacted by COVID-19 at CR, but also after and until September 2021, both on the initial clinical presentation and on postoperative mortality.

Laparoscopic or Open Adrenalectomy for Stage I-II Adrenocortical Carcinoma: A Retrospective Study.

Surgical resection of adrenocortical carcinoma (ACC) is the only curative treatment. Even in localized (I-II) stages, open adrenalectomy (OA) is the gold standard, though laparoscopic adrenalectomy (LA) can be proposed in selected patients. Despite the postoperative benefits of LA, its role in the surgical management of patients with ACC remains controversial regarding oncologic outcomes. The aim of this retrospective study was to compare the outcomes of patients with localized ACC submitted to LA or OA in a referral center from 1995 to 2020. Among 180 consecutive patients operated on for ACC, 49 presented with localized ACC (19 LA and 30 OA). Baseline characteristics were similar between groups, except for tumor size. Kaplan-Meier estimates of 5-year overall survival were similar in both groups (p = 0.166) but 3-year disease-free survival was in favor of OA (p = 0.020). Though LA could be proposed in highly selected patients, OA should still be considered the standard approach in patients with known or suspected localized ACC.

Publication rate and factors associated with publication of research projects by obstetrics residents in an academic department over 10 years.

OBJECTIVES: To determine the publication rate of mandatory research projects conducted by obstetrics residents and to evaluate the publication-associated factors and reported obstacles. STUDY DESIGN: This retrospective cohort study included all consecutive residents in an academic obstetrics-gynecology department in Paris, France, between 2010 and 2020. All residents were required to conduct a research project. Information about publication was collected by searching PubMed. A closed-ended questions questionnaire was sent to former residents about their characteristics, subsequent professional development, and research project characteristics. Factors associated with publication were identified by univariable and multivariable analysis with logistic regression. RESULTS: During the study period, 156 residents trained in our obstetrics-gynecology department. The overall publication rate was 30.8% (48/156) and the median time to publication 27 months (IQR, 18-37). The resident was first author in 36 (75.0%) publications. Among the 130 (83.3%) residents who completed the questionnaire, 43 (33%) had published their research project. Overall, 74/130 (60.8%) residents used their project for their mandatory medical thesis. Factors associated with publication in univariable analysis were younger age (median), completion of a PhD, planned career in academic medicine, prospective study design, presentation at a conference or congress and use their project for their medical thesis. The only factors associated with publication in the multivariable analysis were planned career in academic medicine (aOR 5.62 95 %CI[1.84-17.19]) and the prospective study design of the research project (aOR 6.1 95 %CI[1.24-29.56]). The main reasons for nonpublication reported by resident were lack of time and failure to complete the project. CONCLUSION: Among the mandatory clinical research projects conducted by obstetrics residents over a decade in our department, 30.8% were published. The main factors associated with publication were planned career in academic medicine and a prospective design of the research project.

Impact of COVID-19 lockdowns on postoperative morbidity after hepatectomy: A propensity-score matching study on a national French database.

BACKGROUND: The impact of the SARS-CoV-2 pandemic on managing liver malignancies worldwide is unknown. This study aimed to determine the impact of lockdowns on patient clinical pathways and postoperative morbi-mortality. METHODS: This study evaluated all adults' hospital stays for liver tumors between 2019 and 2021 from the national French discharge database. The primary outcome was the clinical pathway, especially surgical care and postoperative outcomes, between patients admitted during COVID-19 lockdown periods (lockdown group) and during the same periods of 2019 and 2021 (control groups). RESULTS: The overall population included 58,508 patients: 18,907 patients in the lockdown group, 20,045 in the 2019 control group, and 19,556 in the 2021 control group. Surgical activity decreased by 11.6% during lockdowns, with 1,514 (8.0%) of patients in the lockdown group treated by surgery, 1,514 (8.6%) in the 2019 control group (P < .001), and 1,466 (7.4%) in the 2021 control group. Chemotherapy was considered more during the lockdowns (P < .001). More patients were operated in small-volume centers during the lockdowns (34% vs 32% vs 32%, P = .034), and fewer were hospitalized in highly populated regions (P < .001). Postoperative morbidity (47% vs 47% vs 47%, P = .90) and mortality (3.3% vs 3.6% vs 3.1%, P = .80) were comparable in the 3 periods, with no influence of lockdowns on morbidity (risk ratio = 0.94, 95% confidence interval = 0.81-1.09, P = .40) or mortality (odds ratio = 1.12, 95% confidence interval = 0.72-1.74, P = .6). Postoperative pulmonary (17% vs 13%, P = .024) and septic complications (20% vs 15%, P = .022) were significantly higher during the first lockdown compared to the second. CONCLUSION: This study provides a French overview of liver malignancy management during the COVID-19 pandemic. Moreover, surgical activity decreased by 11.6% in high-volume centers, with no impact on postoperative morbidity and mortality.

Positive Correlation Between 18 F-FDG Uptake and Tumor-Proliferating Antigen Ki-67 Expression in Adrenocortical Carcinomas.

PURPOSE OF THE REPORT: Adrenocortical carcinoma (ACC) is an extremely rare endocrine malignancy, which cannot always be diagnosed during conventional radiology and hormonal investigations. 18 F-FDG PET could help predict malignancy, but more data are necessary to support future guidelines. METHODS: A cohort of 63 patients with histologically proven ACC (n = 55) or metastatic ACC with steroid oversecretion (n = 8) was assembled. All patients underwent an 18 F-FDG PET, and the SUV max and the adrenal-to-liver SUV max ratio were calculated. The 18 F-FDG PET parameters were compared with clinical, pathological, and outcome data. RESULTS: Fifty-six of 63 patients (89%) had an ACC with an adrenal-to-liver SUV max ratio >1.45, which was a previously defined cutoff value to predict malignancy with 100% sensitivity. Seven ACCs (11%) had a lower uptake (adrenal-to-liver SUV max <1.45), most of them with a proliferation marker Ki-67 expression level <10%. A positive correlation between 18 F-FDG PET parameters (SUV max and adrenal-to-liver SUV max ratio) and tumor size, ENSAT (European Network for the Study of Adrenal Tumors) staging, total Weiss score, and the Ki-67 was found. The strong correlation between SUV max and Ki-67 ( r = 0.47, P = 0.0009) suggests a relationship between 18 F-FDG uptake levels and tumor proliferation. No statistically significant associations between outcome parameters (progression-free or overall survival) and 18 F-FDG PET parameters were found. CONCLUSIONS: This large cohort study shows that most cases of ACC demonstrate high 18 F-FDG uptake. However, the positive correlation observed between SUV max and Ki-67 expression levels seems to explain the possibility of identifying some ACC with a low or inexistent 18 F-FDG uptake. These findings have practical implications for the management of patients with an adrenal mass.

Multiple Laparoscopic Liver Resection for Colorectal Liver Metastases.

Over the past decades, liver cancer's minimally invasive approach has primarily become as a new standard of oncological care. Colorectal liver metastases (CRLM) are one of the most developed indications of laparoscopic liver resection (LLR). CRLM resection is still the best treatment known in terms of survival. As multiple CRLM are found in up to 80% of cases at diagnosis (Manfredi S. and al, Annals of Surgery 2006), a lot of possible technical management approaches are described. With the development of the parenchymal-sparing strategy, multiple concomitant laparoscopic liver resections (LLR) are gaining acceptance. However, no recommendation is available regarding its indications and feasibility. Also, laparoscopic two-stage hepatectomy is developing for bilobar CRLM, and this also does not have established recommendation. The purpose of this paper was to highlight novelty and updates in the field of multiple minimally invasive liver resections. A review of the international literature was performed. The feasibility of laparoscopic concomitant multiple LLR and two-stage hepatectomy for CRLM as well as their outcomes were discussed. These clarifications could further guide the implementation of minimal resection in multiple colorectal liver metastases therapies.

Artificial intelligence in adrenal imaging: A critical review of current applications.

In the elective field of adrenal imaging, artificial intelligence (AI) can be used for adrenal lesion detection, characterization, hypersecreting syndrome management and patient follow-up. Although a perfect AI tool that includes all required steps from detection to analysis does not exist yet, multiple AI algorithms have been developed and tested with encouraging results. However, AI in this setting is still at an early stage. In this regard, most published studies about AI in adrenal gland imaging report preliminary results that do not have yet daily applications in clinical practice. In this review, recent developments and current results of AI in the field of adrenal imaging are presented. Limitations and future perspectives of AI are discussed.