Staged Double Hepatectomy, Double Total Vascular Exclusion, and Double Venous Reconstruction by Peritoneal Patches in One Patient with Colorectal Liver Metastases.

BACKGROUND: Surgical resection is the best treatment for colorectal liver metastases with good response to chemotherapy and in the absence of extrahepatic disease.1 With the amelioration of surgical technique, primary and recurrent colorectal liver metastases with venous invasion can be resected safely under short total vascular exclusion (TVE), and associated right thoracotomy can have a major benefit if resection at the hepato-caval junction is planned.2 The availability of the peritoneum as an autologous graft for venous reconstruction considerably facilitates the task of the surgeon.3 In this video, we present a patient who had staged double liver resection, double TVE, and double venous reconstruction by a peritoneal graft on the vena cava and the hepatic vein. METHODS: In March 2017, a 47-year-old female was diagnosed with rectal cancer and synchronous liver metastases, microsatellite stability, and Kras mutation. The patient received folinic acid, fluorouracil, and oxaliplatin (FOLFOX) chemotherapy, with good response and a decrease in tumor markers. After chemotherapy, a computed tomography (CT) scan showed one lesion located on the right liver with lateral invasion of the vena cava, and another lesion located in segment I. A liver-first strategy was decided and, in October 2017, the patient had a right hepatectomy extended to segment I and partially on the diaphragm, with lateral resection of the vena cava under isolated clampage of the vena cava and reconstruction with a peritoneal graft (60 mm). The patient received FOLFOX adjuvant chemotherapy for 3 months, and, while under radiotherapy for the rectal cancer, recurrence was diagnosed on the left liver lobe (two lesions), with lateral invasion of the left hepatic vein. Chemotherapy was shifted to folinic acid, fluorouracil, and irinotecan (FOLFIRI)-Avastin, with good response, allowing resection of the primary (T3N0M1), followed by adjuvant chemotherapy. In May 2019, the patient underwent two large resections on the left liver, including one under TVE, with opening of the diaphragm and intrathoracic control of the vena cava. The left hepatic vein was reconstructed laterally with a peritoneal graft (30 mm). RESULTS: Postoperative outcome was uneventful and the two hospital stays were 12 and 15 days, respectively. For the first hepatectomy, pathological examination showed two lesions (80 and 50 mm) with a residual tumor at 10% and R0 resection, and, for the second resection, pathological examination showed two lesions (18 and 20 mm) with residual tumor at 40-60% and R0 resection. In both cases, the tumor was in contact with the resected vein without wall infiltration. The reconstructed vena cava and hepatic vein were patent without stenosis. The patient is disease-free 3 years after the diagnosis. CONCLUSION: Improvements in surgical technique combined with short TVE and associated thoracotomy allow some complicated liver resections to be performed safely. The use of the peritoneum for venous reconstruction is of great benefit in relation to safety and availability, especially in 'redo' liver surgery where intense adhesions can be encountered.

Root cause analysis of mortality after esophagectomy for cancer: a multicenter cohort study from the FREGAT database.

BACKGROUND: Esophagectomy is associated with significant mortality. A better understanding of the causes leading to death may help to reduce mortality. A root cause analysis of mortality after esophagectomy was performed. METHODS: Root cause analysis was retrospectively applied by an independent expert panel of 4 upper gastrointestinal surgeons and 1 anesthesiologist-intensivist to patients included in the French national multicenter prospective cohort FREGAT between August 2014 and September 2019 who underwent an esophagectomy for cancer and died within 90 days of surgery. A cause-and-effect diagram was used to determine the root causes related to death. Death was classified as potentially preventable or non-preventable. RESULTS: Among the 1,040 patients included in the FREGAT cohort, 70 (6.7%) patients (male: 81%, median age 68 [62-72] years) from 17 centers were included. Death was potentially preventable in 37 patients (53%). Root causes independently associated with preventable death were inappropriate indication (odds ratio 35.16 [2.50-494.39]; P = .008), patient characteristics (odds ratio 5.15 [1.19-22.35]; P = .029), unexpected intraoperative findings (odds ratio 18.99 [1.07-335.55]; P = .045), and delay in diagnosis of a complication (odds ratio 98.10 [6.24-1,541.04]; P = .001). Delay in treatment of a complication was found only in preventable deaths (28 [76%] vs 0; P < .001). National guidelines were less frequently followed (16 [43%] vs 22 [67%]; P = .050) in preventable deaths. The only independent risk factor of preventable death was center volume <26 esophagectomies per year (odds ratio 4.71 [1.55-14.33]; P = .006). CONCLUSIONS: More than one-half of deaths after esophagectomy were potentially preventable. Better patient selection, early diagnosis, and adequate management of complications through centralization could reduce mortality.

Circumferential esophageal replacement by a decellularized esophageal matrix in a porcine model.

BACKGROUND: Tissue engineering is an attractive alternative to conventional esophageal replacement techniques using intra-abdominal organs which are associated with a substantial morbidity. The objective was to evaluate the feasibility of esophageal replacement by an allogenic decellularized esophagus in a porcine model. Secondary objectives were to evaluate the benefit of decellularized esophagus recellularization with autologous bone marrow mesenchymal stromal cells and omental maturation of the decellularized esophagus. METHODS: Eighteen pigs divided into 4 experimental groups according to mesenchymal stromal cells recellularization and omental maturation underwent a 5-cm long circumferential replacement of the thoracic esophagus. Turbo green florescent protein labelling was used for in vivo mesenchymal stromal cells tracking. The graft area was covered by a stent for 3 months. Clinical and histologic outcomes were analyzed over a 6-month period. RESULTS: The median follow-up was 112 days [5; 205]. Two animals died during the first postoperative month, 2 experienced an anastomotic leakage, 13 experienced a graft area stenosis following stent migration of which 3 were sacrificed as initially planned after successful endoscopic treatment. The stent could be removed in 2 animals: the graft area showed a continuous mucosa without stenosis. After 3 months, the graft area showed a tissue specific regeneration with a mature epithelium and muscular cells. Clinical and histologic results were similar across experimental groups. CONCLUSION: Circumferential esophageal replacement by a decellularized esophagus was feasible and allowed tissue remodeling toward an esophageal phenotype. We could not demonstrate any benefit provided by the omental maturation of the decellularized esophagus nor its recellularization with mesenchymal stromal cells.

Tumor downstaging after neoadjuvant chemotherapy determines survival after surgery for gastric adenocarcinoma.

BACKGROUND: Since 2006, surgery combined with perioperative chemotherapy is the standard of care for resectable gastric adenocarcinoma in Europe. Specific effects of neoadjuvant chemotherapy remain unknown. The aim was to evaluate the rate of tumor downstaging and its impact on survival in patients undergoing curative resection after neoadjuvant chemotherapy (NeoCT) for gastric adenocarcinoma. MATERIAL AND METHODS: All patients treated in a curative intent for gastric or esophagogastric junction adenocarcinomas between 1996 and 2016 in our high-volume center were retrospectively included. Tumor downstaging after NeoCT was defined as ypTN inferior to cTN. The accuracy of clinical staging was evaluated in patients treated by upfront surgery before 2006. RESULTS: During the study period, 491 patients were operated for gastric adenocarcinoma, and 449 patients were finally analyzed. Among the 163 (36.3%) patients who received NeoCT, 61 (37.4%) had tumor downstaging. Overall survival and disease-free survival were longer in patients with tumor downstaging compared to patients without it (5-year survival: 84.8% vs 49.7%; P = .002 and 61.7% vs 43.4%; P = .054). In multivariate analysis tumor downstaging was an independent prognosis factor for better overall survival (HR = 5.258; P = .002) and disease-free survival (HR = 2.286; P = .028). Moreover, 45.5% of patients staged cT1-T2N0, in whom upfront surgery was performed, were understaged and ultimately had a more advanced tumor on pathological analysis. CONCLUSION: Response to neoadjuvant chemotherapy constitutes a major prognostic factor for overall and disease-free survival. In the absence of predictive factors for tumor downstaging, the indication for perioperative chemotherapy should remain broad, in particular because of the low accuracy of pretherapeutic staging and therefore the high risk of understaging tumors.

Fistulojejunostomy for Chronic Fistula After Sleeve Gastrectomy.

The most dreadful complication after sleeve gastrectomy (SG) is staple line leak. Its rate varies between 1 and 2%. With the development of interventional endoscopy, its treatment is currently fairly standardized and allows healing in the majority of cases without revisional surgery. However, if endoscopic treatment fails, surgical treatment becomes unavoidable. Fistulojejunostomy is a surgical option in the management of chronic fistula after SG. Laparoscopic fistulojejunostomy in a patient with chronic fistula after SG is difficult but feasible. This procedure allows complete healing and nutritional recovery in the case of failure of other endoscopic modalities.

Long-Term Evaluation of Biliary Reflux on Esogastric Mucosae after One-Anastomosis Gastric Bypass and Esojejunostomy in Rats.

BACKGROUND: One-anastomosis gastric bypass/mini-gastric bypass (OAGB/MGB) remains controversial because it may cause chronic biliary reflux (BR). The risk of developing esogastric cancer due to BR after OAGB/MGB is based on the results of experimental rat studies using esojejunostomy (EJ). The aim of this study was to analyze the potential long-term consequences of BR on the esogastric mucosae in OAGB/MGB-operated rats and to compare these results to those from the use of EJ. METHODS: Wistar rats received OAGB/MGB (n = 16), EJ (n = 16), and sham (n = 8) operations. Mortality and weight changes were evaluated throughout the experiment. BR was measured using magnetic resonance imaging (MRI). Rats received follow-ups for 30 weeks. A double-blinded histological analysis was performed in the esogastric segments. RESULTS: BR was diagnosed in OAGB/MGB and EJ rats using the MRI technique; no BR occurred in the sham group. After a 30-week follow-up, no incidences of dysplasia or cancer were observed in the three groups. Additionally, esophageal intestinal metaplasia and mucosal ulcerations were observed in 41.7% and 50% of EJ rats, respectively, and no incidences of these conditions were observed in OAGB/MGB and sham rats. The incidence of esophagitis was significantly higher and more severe in the EJ group compared to those in the OAGB/MGB and sham groups (EJ = 100%, OAGB/MGB = 16.7%, sham = 8.3%; p < 0.001). CONCLUSIONS: After a 30-week follow-up period, OAGB/MGB rats did not develop any precancerous or cancerous lesions when more than 40% of EJ rats had intestinal metaplasia.