Critical appraisal of surgical margins according to KRAS status in liver resection for colorectal liver metastases: Should surgical strategy be influenced by tumor biology?

BACKGROUND: KRAS mutation is a negative prognostic factor for colorectal liver metastases. Several studies have investigated the resection margins according to KRAS status, with conflicting results. The aim of the study was to assess the oncologic outcomes of R0 and R1 resections for colorectal liver metastases according to KRAS status. METHODS: All patients who underwent resection for colorectal liver metastases between 2010 and 2015 with available KRAS status were enrolled in this multicentric international cohort study. Logistic regression models were used to investigate the outcomes of R0 and R1 colorectal liver metastases resections according to KRAS status: wild type versus mutated. The primary outcomes were overall survival and disease-free survival. RESULTS: The analysis included 593 patients. KRAS mutation was associated with shorter overall survival (40 vs 60 months; P = .0012) and disease-free survival (15 vs 21 months; P = .003). In KRAS-mutated tumors, the resection margin did not influence oncologic outcomes. In multivariable analysis, the only predictor of disease-free survival and overall survival was primary tumor location (P = .03 and P = .03, respectively). In KRAS wild-type tumors, R0 resection was associated with prolonged overall survival (74 vs 45 months, P < .001) and disease-free survival (30 vs 17 months, P < .001). The multivariable model confirmed that R0 resection margin was associated with prolonged overall survival (hazard ratio = 1.43, 95% confidence interval: 1.01-2.03) and disease-free survival (hazard ratio = 1.42; 95% confidence interval: 1.06-1.91). CONCLUSIONS: KRAS-mutated colorectal liver metastases showed more aggressive tumor biology with inferior overall survival and disease-free survival after liver resection. Although R0 resection was not associated with improved oncologic outcomes in the KRAS-mutated tumors group, it seems to be of paramount importance for achieving prolonged long-term survival in KRAS wild-type tumors.

Assessing the time-to-removal of totally implantable venous access devices comparing valved-versus open-ended catheters in patients treated with chemotherapy.

BACKGROUND: Totally IntraVenous Acess Devices (TIVAD) are used to have long-term bloodstream access. The catheter connected to the subcutaneous chamber may be valved (TIVAD-V) or open-ended (TIVAD-O). Infectious and occlusion complications require the removal of the TIVAD. We compared the two types of catheters (TIVAD-V and TIVAD-O) in terms of time-to-removal and complication rates. METHODS: A retrospective study of 636 patients treated for any malignancy using a TIVAD were included. TIVAD complication was defined as the occurrence of infection or occlusion requiring TIVAD removal. Risk factors of complications and time-to-removal of TIVAD were assessed by a Cox proportional hazard analysis. RESULTS: A total of 55 TIVADs (8.7%) were removed including 47 for infection and eight for occlusion in 54 months. There was no significant difference in the frequency of complications between TIVAD-V and TIVAD-O. There was no significant difference in time-to-removal between TIVAD-V and TIVAD-O (17.0 months, IQR [10.5-25.0] and 18.4 months, IQR [11.5-22.9], p = 0.345, respectively). CONCLUSION: There was no difference between TIVAD with valved and open catheter in terms of complications and time-to-removal in patients treated by chemotherapy.

Anterior Versus Classical Approach During Right Hepatectomy for Hepatocellular Carcinoma: Inverse Propensity Score Weighted Analysis.

BACKGROUND: Eastern data highlight the oncological benefits of the anterior approach (AA) during right hepatectomy (RH) for hepatocellular carcinoma (HCC). However, to our knowledge, previous western data on this topic are scarce. In this study, the oncological outcomes of AA and classical approach (CA) during RH for HCC were compared. METHODS: A retrospective inverse propensity score-weighted fashion (IPTW) case-control study was performed in two French hepatobiliary surgery departments. Overall survival (OS), disease-free survival (DFS), and early recurrence rate (within 2 years after surgery) were analyzed. RESULTS: Survival analysis was performed for 114 patients (CA group,60 patients; AA group, 54 patients). Before IPTW adjustment, the 3-year DFS rates were 29.4% (AA group) and 44% (CA group), respectively. No significant differences were found in DFS (HR = 1.1, 95%CI:0.62-1.9, p = 0.77) and OS (HR = 1.2, 95%CI:0.54-2.6, p = 0.66). After IPTW, DFS and OS analyses showed no differences between the two groups (p = 0.77 and p = 0.46, respectively). Early recurrence rates were similar before and after IPTW. Satellite nodules were the only significant independent risk factor for recurrence. CONCLUSION: AA and CA did not result in significant differences in DFS, OS, or early recurrence after right hepatectomy for HCC before and after IPTW.

High amylase concentration in drainage liquid can early predict proximal and distal intestinal anastomotic leakages: A prospective observational study.

Background: Anastomotic leak (AL) is a serious complication in digestive surgery. Early diagnosis might allow clinicians to anticipate appropriate management. The aim of this study was to assess the predictive value of amylase concentration in drain fluid for the early diagnosis of digestive tract AL. Materials and Methods: Hundred and fourteen consecutive patients "at risk" of AL, in whom a flexible drainage was placed by surgeon's choice after digestive anastomosis were included. Patients with eso-gastric, bilio-digestive, and pancreatic anastomoses were excluded. Drain amylase measurement (DAM) was routinely performed on postoperative day (POD) 1, 3, 5-7. DAM values were compared between patients with postoperative AL versus patients without AL. A receiver-operating curve (ROC) with calculation of the areas under the ROC curves area under curves was performed and a cutoff value of DAM was calculated. Results: AL occurred in 25 patients (AL group) and 89 patients did not present AL (C group). The mean DAM was significantly higher in AL group versus C Group on POD 1, 3, and 5. A cutoff value of 307 IU/L predicted the occurrence of AL with a sensitivity and specificity of 91% and 100%, respectively. Positive and negative predictive values were 100% and 97.5%, respectively. Patients with AL had an elevated DAM prior to the appearance of any clinical signs of AL. Conclusion: High level DAM could accurately predict AL for proximal and distal digestive tract anastomoses. This simple, noninvasive, and low-cost method can accurately predict early AL and help physicians to perform appropriate imaging and treatment.

Transversus Abdominis Plane Block in the Treatment of Chronic Postsurgical Abdominal Wall Pain Improves Patient Quality of Life: A Retrospective Study and Literature Review.

BACKGROUND: Although poorly studied, chronic postsurgical neuropathic pain (CPNP) represents the second most frequent chronic neuropathic pain etiology, probably affecting 0.5% to 75% of patients with a severe impact on quality of life (QoL). No consensus or treatment algorithm has been elaborated to date, despite a large variety of approaches now available. Transversus abdominis plane (TAP) block has been endorsed as an efficient treatment for acute postoperative pain although its effect on CPNP in terms of intensity and QoL has yet to be considered. OBJECTIVES: The main aim of this study was to evaluate the efficacy of TAP blocks in terms of QoL on patients suffering from abdominal CPNP, including a socio-economic analysis. Results were compared with those published in the recent literature. STUDY DESIGN: Retrospective, monocentric, observational clinical study. SETTING: This single-center retrospective study was conducted at the Chronic Pain Center, Department of Anesthesia, Robert Debré University Hospital, Reims, France. METHODS: From January 2018 through April 2021, all patients suffering from abdominal CPNP treated with a TAP block were enrolled. QoL was assessed using the SF-12 survey. Socio-economic and demographic data were also collected. A literature review was performed using appropriate Medical Subject Headings (MeSH) terms. RESULTS: A TAP block was administered to 44 consecutive patients suffering from CPNP. After a mean follow-up of 11.8 weeks, 86.7% of the patients reported significant effectiveness of the treatment, including an improvement in QoL (P < 0.001), pain scale ratings (P < 0.001) and analgesic requirement (P < 0.001). In term of socio-economic results, one-fifth of the patients returned to work after treatment. The literature review yielded 60 research studies, only 2 of which met our inclusion criteria. These retrospective studies indicated a 76.5% and 81.9% efficacy rate after 12 and 15.5 weeks, respectively. LIMITATIONS: This was a retrospective study with a small sample size. Further investigation should include medical and economic parameters as well as a comparison of TAP block with second-line drug therapies such as transcutaneous neurostimulation, and capsaicin and lidocaine patches. Other anesthetic molecules such as onobotulinumtoxin A (botulinum toxin) combined with steroids should be assessed for these patients. CONCLUSION: The TAP block is easy to learn, easy to reproduce, and easy to administer. After pooling our results with those from the literature, a TAP block is deemed to be effective for the treatment of CPNP with 82.25% effectiveness over a mean time of 13.9 weeks. A TAP block improves long-term QoL, reduces consumption of painkillers and lowers pain scale scores. Thus, it may reduce health care costs. We argue that A TAP block should be considered early, from the onset of the first pain symptoms.

Lichtenstein versus TIPP versus TAPP versus TEP for primary inguinal hernia, a matched propensity score study on the French Club Hernie Registry.

PURPOSE: Groin hernia repair is one of the most frequent operation performed worldwide. Chronic postoperative inguinal pain (CPIP) is the most common and challenging complication after surgical repair with subsequent high socio-economic impact. The aim of this study was to compare the one-year CPIP rates between Lichtenstein, trans-inguinal pre-peritoneal (TIPP), trans-abdominal pre-peritoneal (TAPP) and totally extra-peritoneal (TEP) repair techniques on the French Hernia Registry. METHODS: Between 2011 and 2021, 15,161 primary groin hernia repairs with 1-year follow-up were available on the register. Using propensity score (PS) matching, matched pairs were formed. Each group was compared in pairs independently; Lichtenstein versus TIPP, TEP and TAPP, TIPP versus TEP and TAPP and finally TEP versus TAPP. RESULTS: After PS matching analysis, Lichtenstein group showed disadvantage over TIPP, TAPP and TEP groups with significantly more CPIP at one year (15.2% vs 9.6%, p < 0.0001; 15.9% vs. 10.0%, p < 0.0001 and 16.1% vs. 12.4%, p = 0.002, respectively). The 1-year CPIP rates were similar comparing TIPP versus TAPP and TEP groups (9.3% vs 10.5%, p = 0.19 and 9.8% vs 11.8%, p = 0.05, respectively). There was significantly less CPIP rate after TAPP versus TEP repair (1.00% vs 11.9%, p = 0.02). CONCLUSION: This register-based study confirms the higher CPIP risk after Lichtenstein repair compared to the pre-peritoneal repair techniques. TIPP leads to comparable CPIP rates than TAPP and TEP repairs.

Neoadjuvant chemotherapy for borderline resectable and upfront resectable pancreatic cancer increasing overall survival and disease-free survival?

Background: Pancreatic ductal adenocarcinoma (PDAC) is the most common pancreatic neoplasm. Surgery is the factual curative option, but most patients present with advanced disease. In order to increase resectability, results of neoadjuvant chemotherapy (NAC) on metastatic disease were extrapolated to the neoadjuvant setting by many centers. The aim of our study was to retrospectively evaluate the outcome of patients who underwent upfront surgery (US)-PDAC and borderline (BR)-PDAC, and those resected after NAC to determine prognostic factors that might affect the outcome in these resected patients. Methods: One hundred fifty-one patients between January 2012 and March 2021 in our department were reviewed. Epidemiological characteristics and pre-operative induction treatment were assessed. Pathological reports were analyzed to evaluate the quality of oncological resection (R0/R1). Post-operative mortality and morbidity and survival data were reviewed. Results: One hundred thirteen patients were addressed for US, and 38 were considered BR and referred for surgery after induction chemotherapy. The pancreatic resection R0 was 71.5% and R1 28.5%. pT3 rate was significantly higher in the US than BR (58,4% vs 34,2%, p= 0.005). The mean OS and DFS rates were 29.4 months 15.9 months respectively. There was no difference between OS and DFS of US vs BR patients. N0 patients had significantly longer OS and DFS (p=<0.001). R0 patients had significantly longer OS (p=0.03) and longer DFS (P=0.08). In the multivariate analysis, the presence of postoperative pancreatic fistula, R1 resection, N+ and not access to adjuvant chemotherapy were bad prognostic factors of OS. Conclusions: Our study suggests the benefits of NAC for BR patients in downstaging tumors and rendering them amenable to resection, with same oncological result compared to US.

Asymptomatic stenosis of a celiacomesenteric trunk.

Celiacomesenteric trunk is a rare variant of celiac artery anatomical variations. Stenosis of celiacomesenteric trunk is a severe usually symptomatic condition which might jeopardize the arterial supply of both supramesocolic organs and the midgut. It was diagnosed in a 79-year-old male during the preoperative workup for a pancreatic adenocarcinoma. Highly developed arterial anastomotic arcades, and mainly Riolan arcade, allowed to bypass this stenosis and to avoid digestive ischemia. Arterial anastomotic arcades are of paramount interest to ensure sufficient supply to the corresponding organs and must be thoroughly evaluated before planned surgery to avoid postoperative ischemia.

Concept of reintervention with thorough lymphadenectomy after suboptimal resection of small-intestine neuroendocrine neoplasms: A multicentre preliminary study.

Complete surgical resection is the only hope to cure small intestine neuroendocrine neoplasms (SiNENs). However, inadequate lymphadenectomy or entire small bowel palpation for multiple primary tumours renders at least 20% of resections suboptimal. This study was undertaken to investigate reintervention outcomes after initial suboptimal resections (ISORs), and agreement between residual tumour identification on interval imaging and during reintervention. This retrospective, multicentre study included all patients undergoing reintervention within 18 months post ISOR. Disease-free survival (DFS) was defined as the time from reintervention resection date to recurrence or any-cause of death. The kappa coefficient assessed agreement rates between suspected residual tumour on interval imaging and its presence at reintervention. A total of 21 patients underwent reintervention for nonmetastatic SiNENs (median follow-up 2.3 [IQR 0.6-3.75] years). Residual tumour, suspected in 17/21 (81%) patients based on interval imaging, was found in 20/21 (95%) during reintervention. Interval imaging-intraoperative detection agreement was fair for residual primary tumours (kappa = 0.28, 95% CI: 0.05-0.62; p = .09) and residual lymph node metastases (kappa = 0.17, 95% CI: 0.28-0.62; p = .45). Reintervention achieved complete tumour clearance in 16/21 (76%) patients, among whom 5/16 (31%) developed liver metastases during follow-up. Median DFS was 70.6 months (IQR 39.7-not reached). Reintervention post-ISOR can obtain tumour clearance and prolonged remission. It should be systematically discussed after suspected ISOR, even when postoperative imaging does not find any residual tumour. To maximize detection of potentially resectable residual disease, imaging modalities after "curative" surgery should be redefined.

Microwave Ablation for Colorectal Liver Metastases: A Systematic Review and Pooled Oncological Analyses.

(1) Background: colorectal liver metastases (CRLM) are the most common extra-lymphatic metastases in colorectal cancer; however, few patients are fit for curative surgery. Microwave ablation (MWA) showed promising outcomes in this cohort of patients. This systematic review and pooled analysis aimed to analyze the oncological results of MWA for CRLM. (2) Methods: Following PRISMA guidelines, PubMed, Scopus, EMBASE, Google Scholar, Science Direct, and the Wiley Online Library databases were searched for reports published before January 2021. We included papers assessing MWA, treating resectable CRLM with curative intention. We evaluated the reported MWA-related complications and oncological outcomes as being recurrence-free (RF), free from local recurrence (FFLR), and overall survival rates (OS). (3) Results: Twelve out of 4822 papers (395 patients) were finally included. Global RF rates at 1, 3, and 5 years were 65.1%, 44.6%, and 34.3%, respectively. Global FFLR rates at 3, 6, and 12 months were 96.3%, 89.6%, and 83.7%, respectively. Global OS at 1, 3, and 5 years were 86.7%, 59.6%, and 44.8%, respectively. A better FFLR was reached using the MWA surgical approach at 3, 6, and 12 months, with reported rates of 97.1%, 92.7%, and 88.6%, respectively. (4) Conclusions: Surgical MWA treatment for CRLM smaller than 3 cm is a safe and valid option. This approach can be safely included for selected patients in the curative intent approaches to treating CRLM.

Implications of RAS Mutations on Oncological Outcomes of Surgical Resection and Thermal Ablation Techniques in the Treatment of Colorectal Liver Metastases.

Colorectal cancer (CRC) is the third most common cancer worldwide and the second leading cause of cancer-related death. More than 50% of patients with CRC will develop liver metastases (CRLM) during their disease. In the era of precision surgery for CRLM, several advances have been made in the multimodal management of this disease. Surgical treatment, combined with a modern chemotherapy regimen and targeted therapies, is the only potential curative treatment. Unfortunately, 70% of patients treated for CRLM experience recurrence. RAS mutations are associated with worse overall and recurrence-free survival. Other mutations such as BRAF, associated RAS /TP53 and APC/PIK3CA mutations are important genetic markers to evaluate tumor biology. Somatic mutations are of paramount interest for tailoring preoperative treatment, defining a surgical resection strategy and the indication for ablation techniques. Herein, the most relevant studies dealing with RAS mutations and the management of CRLM were reviewed. Controversies about the implication of this mutation in surgical and ablative treatments were also discussed.

Chemotherapy (doublet or triplet) plus targeted therapy by RAS status as conversion therapy in colorectal cancer patients with initially unresectable liver-only metastases. The UNICANCER PRODIGE-14 randomised clinical trial.

BACKGROUND: Colorectal cancer (CRC) patients have a better prognosis if metastases are resectable. Initially, unresectable liver-only metastases can be converted to resectable with chemotherapy plus a targeted therapy. We assessed which of chemotherapy doublet (2-CTx) or triplet (3-CTx), combined with targeted therapy by RAS status, would be better in this setting. METHODS: PRODIGE 14 was an open-label, multicenter, randomised Phase 2 trial. CRC patients with initially defined unresectable liver-only metastases received either, 2-CTx (FOLFOX or FOLFIRI) or 3-CTx (FOLFIRINOX), plus bevacizumab/cetuximab by RAS status. The primary endpoint was to increase the R0/R1 liver-resection rate from 50 to 70% with the 3-CTx. RESULTS: Patients (n = 256) were mainly men with an ECOG PS of 0, and a median age of 60 years. In total, 109 patients (42.6%) had RAS-mutated tumours. After a median follow-up of 45.6 months, the R0/R1 liver-resection rate was 56.9% (95% CI: 48-66) with the 3-CTx versus 48.4% (95% CI: 39-57) with the 2-CTx (P = 0.17). Median overall survival was 43.4 months with 3-CTx versus 40 months with 2-CTx. CONCLUSION: We failed to increase from 50 to 70% the R0/R1 liver-resection rate with the use of 3-CTx combined with bevacizumab or cetuximab by RAS status in CRC patients with initially unresectable liver metastases.

Small Intestinal Neuroendocrine Neoplasm: Factors Associated with the Development of Local Tumor-Related Symptoms.

INTRODUCTION: Clinical presentations of small intestinal neuroendocrine neoplasms (SiNENs) can range from asymptomatic to life-threatening complications. Other than primary tumor(s), mesenteric mass (MM) can provide local tumor-related (LTR) symptoms. Although some expert centers propose routine primary resection to avoid complications in stage IV patients, some guidelines suggest avoiding primary tumor resection unless in the presence of symptoms. This study was aimed to identify factors associated with the presence or development of LTR symptoms. METHODS: From 2012 to 2019, SiNEN patients with appropriate initial morphological imaging were included. All initial imaging was reviewed. Associations between factors and LTR symptoms were assessed by logistic regression. RESULTS: Among 144 SiNEN patients, 66 met the inclusion criteria. Multivariate analysis identified on initial morphological imaging (i) any visible primary tumor (p < 0.01) and (ii) MM contact ≥180° with the superior mesenteric vessels (p ≤ 0.02), as independent factors associated with LTR symptoms in the whole study population as well as in the subgroup of primary resected patients. Among the 14 (21%) patients with both factors on initial cross-sectional conventional imaging, 12 (18%) were straightaway symptomatic at diagnosis and the remaining became symptomatic during the follow-up. All asymptomatic patients, without upfront surgery and without any predictive factor 16/18 (89%), stayed asymptomatic during the 2.7-year median follow-up. The absence of association between these 2 factors yielded a sensitivity of 100%, a specificity of 62%, and a negative predictive value of 100% for the occurrence of LTR symptoms. CONCLUSION: The presence of any visible primary tumor and/or MM superior mesenteric vessels contact ≥180° at initial cross-sectional imaging are 2 easily identifiable factors, which can help physicians for the decision-making regarding timing and type of surgery for SiNENs. Larger multicenter studies should endorse these results.

A simplified method to evaluate the loss of domain.

PURPOSE: The treatment of giant incisional hernia (IH) with loss of domain (LOD, IHLD) is considerably challenging due to technical difficulties and subsequent post-operative complications. These post-operative risks may be anticipated by calculating the abdominal cavity (AC) volume (ACV) and the IH volume (IHV) on the preoperative CT-scans, using the AC and IH dimensions (Tanaka's method) or using tridimensional volumetry (Sabbagh's method). These techniques are often time-consuming and require specific softwares. The aim of the present study was to develop a simple method to rapidly obtain the LOD-ratio on the preoperative CT-Scan. METHODS: The CT-scans (n = 89) of patients with IHLD were retrospectively studied. Several ratios were calculated using different parameters of the AC and the IH, including width, height and depth, the areas (axial and sagittal ellipse, as well as freehand sagittal surface areas) and these were compared with the reference methods of Sabbagh et al. and Tanaka et al. RESULTS: The LOD ratios calculated from the two reference methods gave similar results (ICC = 0.82, p < 0.0001). The new "R-ratios" (Reims-ratios) obtained from the IH and AC surface areas measured using the "freehand ROI" tool on sagittal view or roughly evaluated by an ellipse on axial view showed excellent correlation with both reference ratios (all ICC ≥ 0.71, p < 0.0001). CONCLUSION: The LOD ratio may be quickly obtained by drawing two circles on the pre-operative CT scan ("R ratios") and available on the webpage https://romeo.univ-reims.fr/Rratio/ . This will certainly help surgeons to routinely anticipate the post-operative complications before IHLD repair.

Inflammatory biomarkers to predict postoperative infectious complications after cytoreductive surgery and HIPEC for peritoneal carcinomatosis.

BACKGROUND: Early detection of postoperative infectious complications (IC) is crucial after Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). The aim of this study was to evaluate the predictive role of early postoperative inflammatory biomarkers level for the detection of postoperative IC. METHODS: a retrospective study was performed including 199 patients treated with complete CRS/HIPEC for PC from various primary origins from September 2012 to January 2021. Patients were monitored by a routine measurement of inflammatory biomarkers (CRP, leukocytes, neutrophils, lymphocytes, neutrophile-to-lymphocyte ratio and platelets-to-lymphocyte ratio). Inflammatory biomarkers were compared between patients with vs without IC. RESULTS: IC occurred for 68 patients (34.2%). CRP values were significantly higher in patients with IC on POD 3, 5 and 7 (CRP = 166 mg/L [128-244], 155 mg/L [102-222] and 207 mg/L [135-259], respectively). The CRP on POD7, with a cut-off value of 100 mg/L, was an excellent predictor of postoperative IC (AUC = 90.1%). The CRP on POD 5, with a cut-off value of 90 mg/L, was a good predictor of postoperative IC (AUC = 83.2%). NLR values were significantly higher in patients with IC on POD 3, 5 and 7. NLR on POD 5 and 7 higher than 9.7 and 6.3, respectively, were fair predictors (AUC = 70.8 and 79.6, respectively). CONCLUSION: CRP levels between POD3 and 7 are the best predictors of postoperative IC after CRS/HIPEC. The presence of postoperative IC should be suspected in patients with CRP higher than 140 mg/L, 90 mg/L or 100 mg/L on PODs 3, 5 or 7.

Dynamic Prediction of Resectability for Patients with Advanced Ovarian Cancer Undergoing Neo-Adjuvant Chemotherapy: Application of Joint Model for Longitudinal CA-125 Levels.

In patients with advanced ovarian cancer (AOC) receiving neoadjuvant chemotherapy (NAC), predicting the feasibility of complete interval cytoreductive surgery (ICRS) is helpful and may avoid unnecessary laparotomy. A joint model (JM) is a dynamic individual predictive model. The aim of this study was to develop a predictive JM combining CA-125 kinetics during NAC with patients' and clinical factors to predict resectability after NAC in patients with AOC. A retrospective study included 77 patients with AOC treated with NAC. A linear mixed effect (LME) sub-model was used to describe the evolution of CA-125 during NAC considering factors influencing the biomarker levels. A Cox sub-model screened the covariates associated with resectability. The JM combined the LME sub-model with the Cox sub-model. Using the LME sub-model, we observed that CA-125 levels were influenced by the number of NAC cycles and the performance of paracentesis. In the Cox sub-model, complete resectability was associated with Performance Status (HR = 0.57, [0.34-0.95], p = 0.03) and the presence of peritoneal carcinomatosis in the epigastric region (HR = 0.39, [0.19-0.80], p = 0.01). The JM accuracy to predict complete ICRS was 88% [82-100] with a predictive error of 2.24% [0-2.32]. Using a JM of a longitudinal CA-125 level during NAC could be a reliable predictor of complete ICRS.

Diagnosis of postoperative recurrence of Crohn disease with MR-enterography: Value of diffusion-weighted imaging.

PURPOSE: To compare the diagnostic capabilities of MR enterography (MRE) using contrast-enhanced (CE) sequences with those of MRE using diffusion-weighted (DW) imaging for the diagnosis of postoperative recurrence at the neo-terminal ileum and/or anastomosis after ileocolonic resection in patients with Crohn disease (CD), and to clarify the role of additional DW imaging to CE-MRE in this context. MATERIAL AND METHODS: Forty patients who underwent ileal resection for CD, and both endoscopy and MRE within the first year after surgery were included. There were 21 men and 19 women, with a mean age of 38 years±12 (SD) years (range: 18-67 years). MRE examinations were blindly analyzed independently by one senior (R1) and one junior (R2) radiologist for the presence of small bowel postoperative recurrence at the anastomotic site. During a first reading session, T2-, steady-state- and DW-MRE were reviewed (DW-MRE or set 1). During a separate distant session, T2-, steady-state- and CE-MRE were reviewed (CE-MRE or set 2). Lastly, all sequences were analyzed altogether (set 3). Performances of each reader for the diagnosis of postoperative recurrence were evaluated using endoscopic findings as the standard of reference (Rutgeerts score≥i2b). RESULTS: Fifteen patients out of 40 (37.5%) had endoscopic postoperative recurrence at the anastomotic site. Sensitivity for the diagnosis of postoperative recurrence was 73% (95% CI: 51-96%) for R1 and 67% (95% CI: 43-91%) for R2 using set 1, and 80% (95% CI: 60-100%) for both readers using set 2. There was no significant differences in sensitivity between reading set 1 and reading set 2, for either R1 or R2 (R1, P> 0.99; R2, P=0.48). Specificity was 96% (95% CI: 88-100%) for both readers using set 1 or using set 2. Reading set 3 yielded an area under the ROC curve (AUC) of 0.93 (95% CI: 0.84-1) versus 0.89 (95% CI: 0.75-1) with set 1 (P=0.18) and versus 0.89 (95% CI: 0.78-1) with set 2 (P=0.21). No significant differences in AUC were found between set 1 or 2 and set 3 (P=0.18), nor between set 1 and 2 (P=0.76). Accuracies were 88% (95% CI: 74-95%) and 85% (95% CI: 71-93%) for DW-MRE for R1 and R2, respectively; 90% (95% CI: 77-96%) for CE-MRE for both readers; and 93% (95% CI: 80-97%) and 88% (95% CI: 74-95%) for R1 and R2 with set 3, respectively. CONCLUSION: DW-MRE has diagnostic capabilities similar to those of CE-MRE for the diagnosis of postoperative recurrence of CD at the anastomotic site.

Laparoscopic hybrid pancreaticoduodenectomy: Initial single center experience.

BACKGROUNDS/AIMS: Pancreaticoduodenectomy (PD) is the gold standard for the treatment of periampullary tumors. Many specialized centers have adopted the totally laparoscopic or hybrid laparoscopic PD (LPD). However, this procedure has not yet been standardized and serious debate is taking place towards its safety and feasibility. Herein, we report our recent experience whit hybrid-LPD. METHODS: During 2019 in our department 56 PD were performed and 21 (37.5%) underwent hybrid-LPD. We have retrospectively reviewed the short-term outcomes of these patients. RESULTS: Main indication was pancreatic adenocarcinoma (71,4%). The median operative time and intraoperative blood loss were respectively 425 min (range, 226 to 576) and 317 ml (range 60 to 800 ml). Conversion to an open procedure was required in 4 patients (19%): 2 with suspected vein involvement, 1 for mesenteric panniculitis and 1 for biliary injury. The post-operative complication rate was 42.8% (9/21). Regarding post-operative pancreatic fistula, three patients (14.2%) had grade B and 1 grade C (4.7%). Median length of hospital stay was 14 days (range 9-23) and 90- days mortality was 4.7%. The mean number of harvested lymph nodes was 17.7 (range 12 to 26). The rate of margins R0 was 80%; R1 ＞0<1 mm was 10.5% and R1 0 mm was 9.5%. CONCLUSIONS: Hydrid-LPD is safe and feasible. Careful patient selection and increasing experience can reduce the risk of post-operative complications.

Fully laparoscopic thermo-ablation of liver malignancies with or without liver resection: tumor location is an independent local recurrence risk factor.

BACKGROUND: The aim of this study was to analyze risk factors of local recurrence (LR) after exclusive laparoscopic thermo-ablation (TA) with or without associated liver resection. METHODS: Between 2012 and 2017, among 385 patients who underwent 820 TA in our department, 65 (17%) patients (HCC = 11, LM = 54) had exclusive laparoscopic TA representing 112 lesions (HCC = 17, LM = 95). TA was associated with other procedures in 57% of cases (liver resection 81%). All TA were done without liver clamping. Median tumor size was 1.8 cm [ranges from 0.3 to 4.5], 18% of the lesions were larger than 3 cm in size and 11% close to major liver vessels. Tumors locations were 77.5% in right liver, 36% in S7&S8, and 46% in S7&S8&S4a. RESULTS: Mortality was nil and morbidity rate 15.4% including Dindo-Clavien > II grade 3%. The median follow-up was 24 months [0.77-75]. Per lesion LR rate after TA was 18% (n = 19 patients) with a mean time of 7.6 months. Among patients with LR, 18 (95%) could have been re-treated successfully (new resection = 11, re-TA = 7). Multivariate analyses revealed that tumor location in S7 alone, S7&S8 and/or S7, S8, or S4a were independent risk factors of LR after TA. CONCLUSIONS: Exclusive laparoscopic TA is a safe and an effective tool to treat liver malignancies with or without liver resection. Other than classical risk factors, tumor location in upper segments of the liver, are independent risk factors for LR.