Optimal results through enhanced recovery: Achieving textbook outcomes with high compliance in elective liver surgery.

BACKGROUND: Existing studies suggest a positive correlation between high compliance with enhanced recovery programs (ERP) and improved outcomes. While individual outcome measures have advantages, composite benchmarks, such as textbook outcome (TO), offer a more comprehensive assessment of healthcare performance. Given the link between ERP and postoperative outcomes, this study aims to investigate the impact of ERP on TO attainment after liver surgery (LS). METHODS: A prospective multicenter cohort of patients undergoing LS and exposed to ERP from 2016 to 2022 in France was analyzed. The primary outcome was to compare the rates of TO achieved between patients with high ERP compliance (>70%) and those with low ERP compliance (<70%) after LS. RESULTS: A total of 706 patients were included in the study, and 217 (30.7%) achieved TO: 170 patients with high ERP compliance (24%) versus 47 patients (6.6%) with low ERP compliance attained TO (p < 0.001). High ERP compliance was associated to an increased likelihood of achieving TO [odds ratio (OR) = 1.49 (95% CI: 1.01, 2.24); p = 0.049], while cholangiocarcinoma [OR = 0.11 (95% CI: 0.02, 0.39); p = 0.003], high complexity LS [OR = 0.22 (95% CI: 0.13, 0.36); p < 0.001], intraoperative hypotension requiring vasopressors [OR = 0.29 (95% CI: 0.10, 0.68); p = 0.010], and post-operative ileus [OR = 0.08 (95% CI: 0.00, 0.37); p = 0.013] were negatively associated to the likelihood of achieving TO. CONCLUSIONS: Patients with high ERP compliance after LS experience elevated rates of TO, compared to those with low ERP compliance.

Diagnostic Accuracy of Lipase as Early Predictor of Postoperative Pancreatic Fistula: Results from the LIPADRAIN study.

Objective: To evaluate the diagnostic accuracy of drain fluid lipase as an early predictor of postoperative pancreatic fistula and establish the most appropriate day for their measure. Background: Clinically relevant postoperative pancreatic fistula remains a potentially life-threatening complication after pancreatic surgery. Early detection strategies remain key to reduce both the incidence and the burden of pancreatic fistula. Methods: The LIPAse DRAIN (LIPADRAIN) study is a multicenter, prospective diagnostic study conducted in 7 tertiary university hospitals. Drain fluid values to detect clinically relevant postoperative pancreatic fistula from postoperative day 1 to postoperative day 6 were evaluated using receiver operating characteristic curve analysis. A biomarker was considered to be relevant for clinical use if its area under the curve (AUC) was greater than 0.75. Results: Of the 625 patients included in the analysis, clinically relevant postoperative pancreatic fistula occurred in 203 (32%) patients. On postoperative days 3 and 4, drain fluid lipase was a reliable biomarker to detect clinically relevant postoperative pancreatic fistula (AUC: 0.761; 95% confidence interval [CI]: 0.761-0.799 and AUC: 0.784; 95% CI: 0.743-0.821, respectively). On postoperative day 3, with a threshold of 299 units/L, drain fluid lipase yielded a negative predictive value of 51%, sensitivity of 78%, and specificity of 63% for the detection of clinically relevant postoperative pancreatic fistula. Conclusions: In this multicenter prospective study, drain fluid lipase is a reliable biomarker at postoperative days 3 and 4 for the diagnosis of clinically relevant postoperative pancreatic fistula after pancreatic surgery and should be systematically measured on postoperative day 3.

Impact of Positive Resection Margins on Recurrence and Survival Following Resection and Adjuvant Chemotherapy in Pancreatic Cancer: Results of the PRODIGE 24-CCTG PA-6 Randomized Controlled Trial.

OBJECTIVE: This study investigated the correlation between positive resection margins and outcomes in patients with pancreatic ductal adenocarcinoma who underwent surgery and adjuvant chemotherapy according to the pivotal trial PRODIGE 24-CCTG PA-6. BACKGROUND: The primary focus is on elucidating the prognostic significance of specific resection margins, including those associated with the superior-mesenteric vein (SMV), medial, and posterior pancreas. METHODS: The analysis involved 400 patients across multiple centers in France and Canada. Surgical resection and subsequent adjuvant chemotherapy were core interventions. This study assessed the prognostic impact of resection margins, highlighting the significance of standardized pathology assessments. Additionally, the influence of chemotherapy regimen choice, comparing gemcitabine to mFOLFIRINOX, on the implications of positive resection margins was examined. RESULTS: Only three margins, SMV (HR=1.48 95% CI [1.11;1.96], P<.001), medial (HR=1.92 95% CI [1.36;2.73], P<.001) and posterior (HR=1.65 95% CI [1.21;2.24], P=.002), had a significant prognostic impact on disease-free survival and were sufficient compared with the seven recommended margins (Kappa=0.90 95% CI [0.87; 0.94]). R1 status was significant independent prognostic factor for poorer survival in gemcitabine-treasted patients (HR=1.97 95% CI [1.23;3.16], P=.005) but lost its significance with mFOLFIRINOX (HR=1.46 95% CI [0.91;2.35], P=.114). CONCLUSIONS: All efforts should be made to evaluate the three margins of the highest prognostic value, with the others being secondary. A key finding of this study is the likely effect of mFOLFIRINOX on local invasion in operated patients, which seems to correct the impairment related to margin involvement, probably explaining the improvements in DFS and OS.

Unusual massive venous hemorrhage after pancreatoduodenectomy treated by endovascular approach.

Most post-pancreaticoduodenectomy hemorrhages (PPH) are of arterial origin, and some studies have suggested that an interventional radiology approach is most effective in reducing mortality. Venous PPH is rare, and identifying its source can be challenging. We report a case of late venous PPH in the context of a pancreatic fistula following pancreaticoduodenectomy. During surgical exploration, the area of ​​potential bleeding was inaccessible due to major inflammatory adhesions aggravated by the presence of pancreatic fistula and the delay of relaparotomy. No intra-abdominal bleeding was detected on imaging studies or during abdominal exploration; only a massive bleeding through the drain orifice, which required packing, was observed. Percutaneous transhepatic portography was performed to localize and treat the origin of the bleeding. The hemorrhage was successfully treated by endovascular approach. We found no reports in the literature on the use of interventional radiology with venous stenting to treat venous PPH, except in cases of gastrointestinal variceal hemorrhage due to portal occlusion.

Minimally invasive versus open distal pancreatectomy for resectable pancreatic neuroendocrine tumors: A propensity score matched multicentric comparative French study.

BACKGROUND: Minimally invasive surgery has gained momentum for left pancreatic resections. However, debate remains about whether it has any advantage over open surgery for distal pancreatectomy for pancreatic neuroendocrine tumors. METHODS: This retrospective review examined pancreatectomies performed for resectable pancreatic neuroendocrine tumors at 21 centers in France between January 2014 and December 2018. Short and long-term outcomes were compared before and after propensity score matching based on tumor size, sex, age, body mass index, center, and method of pancreatic transection. RESULTS: During the period study, 274 patients underwent left pancreatic resection for pancreatic neuroendocrine tumors [109 underwent distal splenopancreatectomy, and 165 underwent spleen-preserving distal pancreatectomy [(splenic vessel preservation (n = 97; 58.7%)/splenic vessel resection (n = 68; 41.3%)]. Before propensity score matching, minimally invasive surgery was associated with a lower rate of major morbidity (P = .004), lower rate of postoperative delayed gastric emptying (P = .04), and higher rate of "textbook" outcomes (P = .04). After propensity score matching, there were 2 groups of 54 patients (n = 30 distal splenopancreatectomy; n = 78 spleen-preserving distal pancreatectomy). Minimally invasive surgery was associated with less blood loss (P = .05), decreased rate of major morbidity (6% vs. 24%; P = .02), less delayed gastric emptying (P = .05) despite similar rates of postoperative fistula, hemorrhage, and reoperation (P > .05). The 5-year overall survival (79% vs. 75%; P = .74) and recurrence-free survival (10% vs 17%; P = .39) were similar. CONCLUSION: Minimally invasive surgery for left pancreatic resection can be safely proposed for patients with resectable left pancreatic neuroendocrine tumors. Minimally invasive surgery decreases the rate of major complications while providing comparable long-term oncologic outcomes.

Association between polyunsaturated fatty acids in adipose tissue and mortality of colorectal cancer patients.

INTRODUCTION: Nutritional intake and dysregulation of fatty acid metabolism play a role in the progression of various tumors, but the consumption of fatty acids is difficult to assess accurately with dietary questionnaires. Biomarkers can objectively assess intake, storage and bioavailability. OBJECTIVE: We studied the association between the polyunsaturated fatty acid (PUFA) composition of abdominal subcutaneous adipose tissue (good indicator of dietary intake over 2-3 years) and all-cause mortality. METHODS: In the multicenter AGARIC study, samples from 203 patients with colorectal cancer (CRC) undergoing curative surgery, were harvested from subcutaneous adipose tissue, which were then analyzed for PUFA composition. RESULTS: After a median follow-up of 45 months, 76 patients died. These patients were more often men (72.4% versus 57.5%, P = 0.04), diabetic (32.9% versus 13.4%, P = 0.001), old (median: 74.5 versus 66.6 years, P < 0.001) and with high alcohol consumption (47.4% versus 30.7%, P = 0.005). An increased risk of death was observed with higher levels of 20:2 ω-6 (hazard ratiotertile3 vstertile1 (HRT3vsT1) 2.12; 95% confidence interval (CI) 1.01-4.42; p-trend = 0.04), 22:4 ω-6 (HRT3vsT1 = 3.52; 95% CI = 1.51-8.17; p-trend = 0.005), and 22:5 ω-6 (HRT3vsT1 = 3.50; 95% CI = 1.56-7.87; p-trend = 0.002). Conversely, the risk of death seemed lower when higher concentrations of 18:3 ω-6 (HRT3vsT1 = 0.52; 95% CI = 0.27-0.99; p-trend = 0.04) and the essential fatty acid, α-linolenic acid 18:3 ω-3 (HRT3vsT1 = 0.47; 95% CI = 0.24-0.93; p-trend = 0.03) were observed. CONCLUSION: The risk of death was increased in CRC patients with higher concentrations of certain ω-6 PUFAs and lower concentrations of α-linolenic acid in their subcutaneous adipose tissue. These results reflect dietary habits and altered fatty acid metabolism. Our exploratory results warrant confirmation in larger studies with further exploration of the mechanisms involved.

Management and outcomes of hemorrhage after distal pancreatectomy: a multicenter study at high volume centers.

BACKGROUND: Data on clinically relevant post-pancreatectomy hemorrhage (CR-PPH) are derived from series mostly focused on pancreatoduodenectomy, and data after distal pancreatectomy (DP) are scarce. METHODS: All non-extended DP performed from 2014 to 2018 were included. CR-PPH encompassed grade B and C PPH. Risk factors, management, and outcomes of CR-PPH were evaluated. RESULTS: Overall, 1188 patients were included, of which 561 (47.2 %) were operated on minimally invasively. Spleen-preserving DP was performed in 574 patients (48.4 %). Ninety-day mortality, severe morbidity and CR-POPF rates were 1.1 % (n = 13), 17.4 % (n = 196) and 15.5 % (n = 115), respectively. After a median interval of 8 days (range, 0-37), 65 patients (5.5 %) developed CR-PPH, including 28 grade B and 37 grade C. Reintervention was required in 57 patients (87.7 %). CR-PPH was associated with a significant increase of 90-day mortality, morbidity and hospital stay (p < 0.001). Upon multivariable analysis, prolonged operative time and co-existing POPF were independently associated with CR-PPH (p < 0.005) while a chronic use of antithrombotic agent trended towards an increase of CR-PPH (p = 0.081). As compared to CR-POPF, the failure-to-rescue rate in patients who developed CR-PPH was significantly higher (13.8 % vs. 1.3 %, p < 0.001). CONCLUSION: CR-PPH after DP remains rare but significantly associated with an increased risk of 90-day mortality and failure-to-rescue.

Is pancreatic head surgery safe in the elderly?

BACKGROUND: During the last century, life expectancy has doubled. As a result, senior patients with cancer are more frequently referred for possible surgery. Pancreatic surgery is a complex surgery associated with significant postoperative morbidity. Surgical decision-making in the elderly population can be difficult because outcomes in the elderly are poorly defined. Our objective is to characterize differences in mortality and morbidity for pancreatic surgery in the elderly population. METHODS: A retrospective review of all patients undergoing pancreatic head surgery in our tertiary referral center from 2015 to 2021 was conducted. Analysis was performed for the entire cohort, classifying patients into three age groups: <70 years, 70-79 years, and ≥80 years. Data from these three groups were compared, including comorbidity, oncologic outcomes and postoperative complications. RESULTS: A total of 326 patients underwent pancreatic head resection. The 90-day mortality increased from 2.9% to 5.3% to 15.4% with increasing age (p = 0,015). There were no differences among the three groups in terms of postoperative morbidity. There was no difference in disease-free survival (DFS), but overall survival was better in patients under 70 years (p = 0,046). CONCLUSION: Compared to younger patients, patients over 80 years old have a higher risk of mortality despite similar postoperative morbidity.

Preoperative Magnetic Resonance Enterography to Predict Pathological Specimen Length in Crohn's Disease.

BACKGROUND: The European Crohn's and Colitis Organization guidelines have highlighted the importance of the preoperative evaluation of the affected segment length in patients with ileocolic Crohn's disease to determine the best surgical approach. OBJECTIVE: This study aimed to evaluate the accuracy of preoperative magnetic resonance enterography in assessing the length of the affected segment in patients with ileocolic Crohn's disease. DESIGN: This observational study was conducted with a prospectively maintained database and retrospective analysis. SETTINGS: This study was conducted in a tertiary center. PATIENTS: This study included consecutive patients undergoing ileocolic resection for Crohn's disease between August 2014 and June 2020. All patients underwent a preoperative magnetic resonance enterography. MAIN OUTCOME MEASURES: The correlation between the length measured on magnetic resonance enterography and pathological examination was evaluated. RESULTS: A total of 96 patients were included. The median time between magnetic resonance enterography and surgery was 65.5 (3-331) days. The length of the affected segment on magnetic resonance enterography was correlated with the length assessed on pathological evaluation ( R = 0.48, p < 0.001). No correlation was found between the 2 measurements when imaging was performed >6 months before surgery ( R = 0.14, p = 0.62). The presence of an abscess underestimated the length affected by Crohn's disease on imaging compared to pathology, whereas the presence of a fistula was associated with magnetic resonance enterography overestimation of the length of the affected segment. LIMITATIONS: Limitations included single-center study and retrospective analysis. CONCLUSION: In Crohn's disease, preoperative magnetic resonance enterography is a highly reliable tool for predicting the length of the affected segment compared to pathology examination in the absence of an abscess or fistula. See Video Abstract at http://links.lww.com/DCR/C26 . ENTEROGRAFA POR RESONANCIA MAGNTICA PREOPERATORIA PARA PREDECIR LA LONGITUD DE MUESTRAS PATOLGICAS EN LA ENFERMEDAD DE CROHN: ANTECEDENTES:Las guías de la Organización Europea de Crohn y Colitis han resaltado la importancia de la evaluación preoperatoria de la longitud del segmento afectado para determinar el mejor abordaje quirúrgico.OBJETIVO:Evaluamos la precisión de la enterografía por resonancia magnética preoperatoria para evaluar la longitud del segmento afectado en pacientes con enfermedad de Crohn ileocólica.DISEÑO:Realizamos un estudio observacional con una base de datos mantenida prospectivamente y un análisis retrospectivo.CONFIGURACIÓN:Este estudio se realizó en un centro terciario.PACIENTES:Se incluyeron pacientes consecutivos sometidos a resección ileocólica por enfermedad de Crohn entre Agosto de 2014 y Junio de 2020. A todos los pacientes se les realizó una enterografía por resonancia magnética preoperatoria.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluó la correlación entre la longitud medida en la enterografía por resonancia magnética y el examen patológico.RESULTADOS:Se incluyeron un total de 96 pacientes. El tiempo mediano entre la enterografía por resonancia magnética y la cirugía fue de 65,5 (3-331) días. La longitud del segmento afectado en la enterografía por resonancia magnética se correlacionó con la longitud evaluada en la evaluación patológica ( R = 0,48, p < 0,001). No hubo correlación entre las 2 mediciones cuando las imágenes se realizaron más de 6 meses antes de la cirugía ( R = 0,14, p = 0,62). La presencia de un absceso subestimó la longitud afectada por la enfermedad de Crohn en las imágenes en comparación con la patología, mientras que la presencia de una fístula se asoció con una sobrestimación de la longitud del segmento afectado por enterografía por resonancia magnética.LIMITACIONES:Las limitaciones incluyeron un estudio de un solo centro y un análisis retrospectivo.CONCLUSIÓNES:En la enfermedad de Crohn, la enterografía por resonancia magnética preoperatoria es una herramienta altamente confiable para predecir la longitud del segmento afectado en comparación con el examen de patología, en ausencia de absceso o fístula. Consulte el Video Resumen en http://links.lww.com/DCR/C26 . (Traducción-Dr. Yesenia Rojas-Khalil ).

Defining Benchmark Outcomes for Distal Pancreatectomy: Results of a French Multicentric Study.

OBJECTIVE: Defining robust and standardized outcome references for distal pancreatectomy (DP) by using Benchmark analysis. BACKGROUND: Outcomes after DP are recorded in medium or small-sized studies without standardized analysis. Therefore, the best results remain uncertain. METHODS: This multicenter study included all patients undergoing DP for resectable benign or malignant tumors in 21 French expert centers in pancreas surgery from 2014 to 2018. A low-risk cohort defined by no significant comorbidities was analyzed to establish 18 outcome benchmarks for DP. These values were tested in high risk, minimally invasive and benign tumor cohorts. RESULTS: A total of 1188 patients were identified and 749 low-risk patients were screened to establish Benchmark cut-offs. Therefore, Benchmark rate for mini-invasive approach was ≥36.8%. Benchmark cut-offs for postoperative mortality, major morbidity grade ≥3a and clinically significant pancreatic fistula rates were 0%, ≤27%, and ≤28%, respectively. The benchmark rate for readmission was ≤16%. For patients with pancreatic adenocarcinoma, cut-offs were ≥75%, ≥69.5%, and ≥66% for free resection margins (R0), 1-year disease-free survival and 3-year overall survival, respectively. The rate of mini-invasive approach in high-risk cohort was lower than the Benchmark cut-off (34.1% vs ≥36.8%). All Benchmark cut-offs were respected for benign tumor group. The proportion of benchmark cases was correlated to outcomes of DP. Centers with a majority of low-risk patients had worse results than those operating complex cases. CONCLUSION: This large-scale study is the first benchmark analysis of DP outcomes and provides robust and standardized data. This may allow for comparisons between surgeons, centers, studies, and surgical techniques.

Development of a Clinical-Biological Model to Assess Tumor Progression in Metastatic Pancreatic Cancer: Post Hoc Analysis of the PRODIGE4/ACCORD11 Trial.

Background: The follow-up of pancreatic cancer (PC) is based on computed tomography (CT) assessment; however, there is no consensus on the use of clinical and biological criteria in tumor progression. We aimed to establish a clinical−biological model to highlight the progression of metastatic PC during first-line treatment. Methods: The patients treated with first-line chemotherapy in the phase 2/3 PRODIGE4/ACCORD11 clinical trial were evaluated retrospectively. Clinical and biological markers were evaluated at the time of CT scans and during treatment to determine tumor progression. Results: In total, 196 patients were analyzed, with 355 available tumor assessments. The clinical and biological factors associated with tumor progression in multivariate analysis included gemcitabine, global health status ≤ 33 (OR = 3.38, 95%CI [1.15; 9.91], p = 0.028), quality of life score between 34 and 66 (OR = 2.65, 95%CI [1.06; 6.59], p = 0.037), carcinoembryonic antigen (CEA) ≥ 3 times the standard value without any increase in the CEA level from inclusion (OR = 2.22, 95%CI [1.01; 4.89], p = 0.048) and with an increase in the CEA level from inclusion (OR = 6.56, 95%CI [2.73; 15.78], p < 0.001), and an increase in the carbohydrate antigen 19-9 level from inclusion (OR = 2.59, 95%CI [1.25; 5.36], p = 0.016). Conclusions: The self-assessment of patients' general health status alongside tumor markers is an interesting approach to the diagnosis of the tumor progression of metastatic pancreatic cancer patients during first-line treatment.

Benefit of a flash dose of corticosteroids in digestive surgical oncology: a multicenter, randomized, double blind, placebo-controlled trial (CORTIFRENCH).

BACKGROUND: The modulation of perioperative inflammation seems crucial to improve postoperative morbidity and cancer-related outcomes in patients undergoing oncological surgery. Data from the literature suggest that perioperative corticosteroids decrease inflammatory markers and might be associated with fewer complications in esophageal, liver, pancreatic and colorectal surgery. Their benefit on cancer-related outcomes has not been assessed. METHODS: The CORTIFRENCH trial is a phase III multicenter randomized double-blind placebo-controlled trial to assess the impact of a flash dose of preoperative corticosteroids versus placebo on postoperative morbidity and cancer-related outcomes after elective curative-intent surgery for digestive cancer. The primary endpoint is the frequency of patients with postoperative major complications occurring within 30 days after surgery (defined as all complications with Clavien-Dindo grade > 2). The secondary endpoints are the overall survival at 3 years, the disease-free survival at 3 years, the frequency of patients with intraabdominal infections and postoperative infections within 30 days after surgery and the hospital length of stay. We hypothesize a reduced risk of major complications and a better disease-survival at 3 years in the experimental group. Allowing for 5% of drop-out, 1 200 patients (600 per arm) should be included. DISCUSSION: This will be the first trial focusing on the impact of perioperative corticosteroids on cancer related outcomes. If significant, it might be a strong improvement on oncological outcomes for patients undergoing surgery for digestive cancers. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03875690, Registered on March 15, 2019, URL: https://clinicaltrials.gov/ct2/show/NCT03875690 .

Is Hartmann's Pouch an Option in the Management of Acute Severe Ulcerative Colitis?

BACKGROUND: The surgical management of remnant rectosigmoid after subtotal colectomy with end ileostomy for acute severe ulcerative colitis remains controversial with respect to the need to perform sigmoidostomy or Hartmann's pouch. The aim of this retrospective study was to investigate whether Hartmann's pouch may be a safe option. METHODS: Thirty-eight Hartmann's pouches were performed between January 2003 and December 2015. We looked at morbidity (with a focus on the occurrence of pelvic sepsis and leakage of the rectal stump) and the rate of restored intestinal continuity. RESULTS: Nineteen patients had surgical complications. Seven had an intra-abdominal collection, only one of which was in the pelvis, and the patient had to be reoperated. Only one patient had a reopening of the rectal stump, which was revealed by rectal bleeding. Twenty-six patients (68.4%) underwent further proctectomy with ileal J-pouch anal anastomosis with no difficulty in localizing or mobilizing the rectal stump and no major surgical complications. CONCLUSIONS: Hartmann's pouch may be considered in patients with acute severe ulcerative colitis, with low rates of morbidity and pelvic sepsis. The restoration of intestinal continuity is possible after this procedure without any special difficulty.

Weight change after colectomy for ulcerative colitis.

BACKGROUND AND OBJECTIVE: Weight change after colectomy for ulcerative colitis is unknown. The main objective of this study was to describe weight change during surgical management of ulcerative colitis. METHODS: All patients, underwent a subtotal colectomy, then a proctectomy with J ileal pouch anal anastomosis protected by an ileostomy, and finally an ileostomy closure in the context of ulcerative colitis at the Nancy University Hospital from May 2014 to October 2020, were included. For each patient, his healthy weight, preoperative weight and postoperative weight were recorded for each step of surgery. RESULTS: Twenty-six patients were included. The median body mass index of healthy weight was 23.3 kg/m2. Before subtotal colectomy, the median body mass index decreased to 21.3 kg/m2, a reduction of 8.5%. One month after subtotal colectomy, the median body mass index was at its lowest level of 20.8 kg/m2, which represented a 10.7% decrease from the healthy weight. Thereafter a significant increase in body mass index was observed before the proctectomy, reaching the threshold of 22.8 kg/m2, an increase of 8.7% from the lowest level. After the last surgical time, which corresponds to the ileostomy closure, the body mass index was 23.2 kg/m2, this threshold was comparable to the healthy weight body mass index. CONCLUSION: Our study showed for the first time that after colectomy for ulcerative colitis, patients regained their healthy weight, which constitutes a reassuring message for patients before surgery.

Surgical anatomy of hepatic arteries from its origin to segmental branching: A 500 cases CT study.

BACKGROUND: The aim of this study was to present an overview of variations of the hepatic artery from the origin to the segmental branching. METHODS: Abdominal Computed Tomography performed on consecutive patients in our tertiary center between 2019 and 2020 were analyzed. Hepatic arterial branching and its relationship to the portal veins were reported. RESULTS: Out of 500 imaging, 16 anatomic patterns were found for the origin of hepatic artery, with 65.6% conventional origin at celiac axis (n = 328); 10 patterns for the left hepatic artery, 23 for segment IV artery, and more than 21 for the right hepatic artery (RHA), with conventional branching in respectively 66.8%, 39.6% and in 46.4% of patients. Conventional anatomy from celiac axis to segmental branching was found in 10.4% of patients. CONCLUSION: Dedicated thin-section imaging appears to be essential for preoperative planning in liver surgery, given the high variability of arterial distribution and their surgical implications.

Impact of the COVID-19 pandemic on disease stage and treatment for patients with pancreatic adenocarcinoma: A French comprehensive multicentre ambispective observational cohort study (CAPANCOVID).

BACKGROUND: The COVID-19 pandemic caused major oncology care pathway disruption. The CAPANCOVID study aimed to evaluate the impact on pancreatic adenocarcinoma (PA) - from diagnosis to treatment - of the reorganisation of the health care system during the first lockdown. METHODS: This multicentre ambispective observational study included 833 patients diagnosed with PA between September 1, 2019 and October 31, 2020 from 13 French centres. Data were compared over three periods defined as before the outbreak of COVID-19, during the first lockdown (March 1 to May 11, 2020) and after lockdown. RESULTS: During the lockdown, mean weekly number of new cases decreased compared with that of pre-pandemic levels (13.2 vs. 10.8, -18.2%; p = 0.63) without rebound in the post-lockdown period (13.2 vs. 12.9, -1.7%; p = 0.97). The number of borderline tumours increased (13.6%-21.7%), whereas the rate of metastatic diseases rate dropped (47.1%-40.3%) (p = 0.046). Time-to-diagnosis and -treatment were not different over periods. Waiting neoadjuvant chemotherapy in resectable tumours was significantly favoured (24.7%-32.6%) compared with upfront surgery (13%-7.8%) (p = 0.013). The use of mFOLFIRINOX preoperative chemotherapy regimen decreased (84.9%-69%; p = 0.044). After lockdown, the number of borderline tumours decreased (21.7%-9.6%) and advanced diseases increased (59.7%-69.8%) (p = 0.046). SARS-CoV-2 infected 39 patients (4.7%) causing 5 deaths (12.8%). CONCLUSION: This cohort study suggests the existence of missing diagnoses and of a shift in disease stage at diagnosis from resectable to advanced diseases with related therapeutic modifications whose prognostic consequences will be known after the planned follow-up. TRIAL REGISTRATION: Clinicaltrials.gov NCT04406571.

Selective Internal Radiation Combined with Chemotherapy Maintains the Quality of Life in Intrahepatic Cholangiocarcinomas.

BACKGROUND: In the Yttrium-90 Microspheres in Cholangiocarcinoma (MISPHEC) single-arm phase 2 trial, concomitant chemotherapy and selective internal radiotherapy (SIRT) showed antitumor activity as a first-line treatment of unresectable intrahepatic cholangiocarcinomas (ICCs). In this sub-analysis, we aimed to evaluate one of the secondary endpoints, the health-related quality of life (QoL), evaluated with an EORTC QLQ-C30 instrument at the baseline and during treatment. METHODS: The MISPHEC trial included treatment-naïve patients with an unresectable ICC between November 2013 and June 2016. Patients received concomitant first-line chemotherapy with cisplatin and gemcitabine for 8 cycles; SIRT was administered during cycle 1 (for patients with unilobar disease) or cycles 1 and 3 (for patients with bilobar disease) using glass Yttrium-90 microspheres. We evaluated the QoL-measured by the QLQ-C30 questionnaire-at the baseline, every 8 weeks during chemotherapy and follow-up, between 12 and 15 weeks after embolization and every 12 weeks after a liver resection if applicable. RESULTS: A total of 41 patients were included, of which 34 completed questionnaires at the baseline. No clinically significant changes in the global health score or the sub-scales of the QLQ-C30 were observed during follow-up. The physical, social and role function mean score worsened during treatment and fatigue, nausea and pain scores increased although the differences were not clinically significant. In patients undergoing subsequent surgery, the QoL was not impaired. CONCLUSIONS: A combination of SIRT and chemotherapy with gemcitabine and cisplatin as the first-line treatment of unresectable ICCs was found to maintain the QoL.

Liver Venous Deprivation or Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy?: A Retrospective Multicentric Study.

OBJECTIVE: To compare 2 techniques of remnant liver hypertrophy in candidates for extended hepatectomy: radiological simultaneous portal vein embolization and hepatic vein embolization (HVE); namely LVD, and ALPPS. BACKGROUND: Recent advances in chemotherapy and surgical techniques have widened indications for extended hepatectomy, before which remnant liver augmentation is mandatory. ALPPS and LVD typically show higher hypertrophy rates than portal vein embolization, but their respective places in patient management remain unclear. METHODS: All consecutive ALPPS and LVD procedures performed in 8 French centers between 2011 and 2020 were included. The main endpoint was the successful resection rate (resection rate without 90-day mortality) analyzed according to an intention-to-treat principle. Secondary endpoints were hypertrophy rates, intra and postoperative outcomes. RESULTS: Among 209 patients, 124 had LVD 37 [13,1015] days before surgery, whereas 85 underwent ALPPS with an inter-stages period of 10 [6, 69] days. ALPPS was mostly-performed for colorectal liver metastases (CRLM), LVD for CRLM and perihilar cholangiocarcinoma. Hypertrophy was faster for ALPPS. Successful resection rates were 72.6% for LVD ± rescue ALPPS (n = 6) versus 90.6% for ALPPS (P < 0.001). Operative duration, blood losses and length-of-stay were lower for LVD, whereas 90-day major complications and mortality were comparable. Results were globally unchanged for CRLM patients, or after excluding the early 2 years of experience (learning-curve effect). CONCLUSIONS: This study is the first 1 comparing LVD versus ALPPS in the largest cohort so far. Despite its retrospective design, it yields original results that may serve as the basis for a prospective study.

Peritoneal Carcinomatosis Risk and Long-Term Survival Following Hepatectomy for Spontaneous Hepatocellular Carcinoma Rupture: Results of a Multicenter French Study (FRENCH-AFC).

BACKGROUND: Spontaneous rupture of hepatocellular carcinoma (HCC) remains a life-threatening complication, with a reported mortality rate of between 16 and 30% and an incidence rate of approximately 3% in Europe. Survival data and risk factors after ruptured HCC are lacking, especially for peritoneal metastasis (PM). OBJECTIVES: The aims of this study were to evaluate the pattern of recurrence and mortality after hepatectomy for ruptured HCC, and to focus on PM. METHODS: We retrospectively reviewed the files of patients admitted to 14 French surgical centers for spontaneous rupture of HCC between May 2000 and May 2012. RESULTS: Overall, 135 patients were included in this study. The median disease-free survival and overall survival (OS) rates were 16.1 (11.0-21.1) and 28.7 (26.0-31.5) months, respectively, and the median follow-up period was 29 months. At last follow-up, recurrences were observed in 65.1% of patients (n = 88). The overall rate of PM following ruptured HCC was 12% (n = 16). Surgical management of PM was performed for six patients, with a median OS of 36.6 months. An α-fetoprotein level > 30 ng/mL (p = 0.0009), tumor size at rupture > 70 mm (p = 0.0009), and vascular involvement (p < 0.0001) were found to be independently associated with an increased likelihood of recurrence. No risk factor for PM was observed. CONCLUSION: This large-cohort French study confirmed that 12% of patients had PM after ruptured HCC. A curative approach may be an option for highly selected patients with exclusive PD because of the survival benefit it could provide.