Aborted pancreatoduodenectomy after extensive vascular dissection in patients with pancreatic cancer: a word of caution.

BACKGROUND: Difficulties in distinguishing fibrosis from tumor in borderline and locally advanced pancreatic adenocarcinoma (PDAC) justify surgical exploration to assess resectability. This issue is especially relevant after neoadjuvant treatments (NAT) prior to pancreaticoduodenectomy (PD) although outcomes of aborted PD are unknown. OBJECTIVES: This study aimed to evaluate early outcomes after aborted PD in patients with PDAC. METHODS: Data were collected over a ten-year period, in three University Hospitals in France. Perioperative patient management was similar. The causes of intraoperative PD abortions were recorded, and outcomes of patients who underwent early (metastases, carcinomatosis) and late (following extensive vascular dissection) PD abortion were compared. RESULTS: Of 774 PD for PDAC, 131 (17%) were aborted. 97 (74%) patients underwent early PD abortion due to carcinomatosis (n = 14; 14%), liver metastases (n = 32; 33%), aortocaval lymph node invasion (n = 28; 29%) and massive vascular extension (n = 23; 24%). Late PD abortion occurred after extensive vascular dissection in 34 (26%) patients due to invasion of the common hepatic (n = 16; 47%), superior mesenteric (n = 5; 15%) and right hepatic (n = 1; 3%) arteries and nonreconstructable venous invasion (n = 12; 35%). Patients who underwent late PD abortion had higher rates of overall morbidity (n = 22; 65% vs n = 27; 28%, p = 0.0001), severe complications (n = 14; 41% vs n = 11; 11%, p = 0.0005), mortality (n = 4; 12% vs n = 0; 0%, p = 0.003). They also had higher rates of delayed gastric emptying (n = 11; 32% vs n = 6; 6%, p = 0.0003), deep space infections (n = 10; 29% vs n = 7; 7%, p = 0.002), wound infections (n = 5; 15% vs n = 4; 4%, p = 0.05), and bleeding (n = 8; 24% vs n = 0; 0%, p < 0.0001). CONCLUSION: Aborted PD after extensive vascular dissection has high morbidity and mortality rates. Appropriate information and counseling should be delivered to patients with borderline/locally advanced PDAC considered for PD.

Completion pancreatectomy during pancreatoduodenectomy: A lifesaving solution in high-risk patients.

BACKGROUND: Postoperative pancreatic fistula (POPF) is responsible of most major complications and fatalities after PD. By avoiding POPF, TP may improve operative outcomes in high-risk patients. The aim was to compare total pancreatectomy (TP) and pancreatoduodenectomy (PD) in high-risk patients and evaluate results of implementing a risk-tailored strategy in clinical practice. METHODS: Between 2014 and 2023, 139 patients (76 men, median age 67 years) underwent resection of disease located in the head of the pancreas. Starting January 1, 2022, we offered TP to patients at high POPF risks (fistula risk score (FRS) ≥7) and to patients with intermediate POPF risks (FRS: 3-6) and high risks of failure to rescue (age> 75 years, ASA score ≥3). We compared outcomes of TP and PD and evaluated the results of the new strategy implementation on operative outcomes. Propensity score-based analysis was performed to limit bias of between-group comparison. RESULTS: Eventually, 26 (19%) patients underwent TP and 113 (81%) patients underwent PD. Severe complications occurred in 42 (30%) patients and 13 (9%) patients died. TP resulted in shorter lengths of hospital stay (median: 14 days [11; 18] vs. 17 days [13; 24], p = 0.016) and less risks of post-pancreatectomy hemorrhage (PPH) (0% vs. 20%, p < 0.001) compared to PD. Crude and propensity match analysis showed that the implementation of a risk-tailored strategy led to significant reduction of reoperation, POPF, PPH and mortality rates. CONCLUSION: The use of TP as part of a risk-tailored strategy in high-risk patients can be lifesaving.

Comparing indications, complexity and outcomes of laparoscopic liver resection between centers with and without a liver transplant program: a French nationwide study.

BACKGROUND: There are no data to evaluate the difference in populations and impact of centers with liver transplant programs in performing laparoscopic liver resection (LLR). METHODS: This was a multicenter study including patients undergoing LLR for benign and malignant tumors at 27 French centers from 1996 to 2018. The main outcomes were postoperative severe morbidity and mortality. RESULTS: A total of 3154 patients were included, and 14 centers were classified as transplant centers (N = 2167 patients, 68.7 %). The transplant centers performed more difficult LLRs and more resections for hepatocellular carcinoma (HCC) in patients who more frequently had cirrhosis. A higher rate of performing the Pringle maneuver, a lower rate of blood loss and a higher rate of open conversion (all p < 0.05) were observed in the transplant centers. There was no association between the presence of a liver transplant program and either postoperative severe morbidity (<10 % in each group; p = 0.228) or mortality (1 % in each group; p = 0.915). CONCLUSIONS: Most HCCs, difficult LLRs, and cirrhotic patients are treated in transplant centers. We show that all centers can achieve comparable safety and quality of care in LLR independent of the presence of a liver transplant program.

ERS: A simple scoring system to predict early recurrence after surgical resection for hepatocellular carcinoma.

BACKGROUND: Surgical resection (SR) is a potentially curative treatment of hepatocellular carcinoma (HCC) hampered by high rates of recurrence. New drugs are tested in the adjuvant setting, but standardised risk stratification tools of HCC recurrence are lacking. OBJECTIVES: To develop and validate a simple scoring system to predict 2-year recurrence after SR for HCC. METHODS: 2359 treatment-naïve patients who underwent SR for HCC in 17 centres in Europe and Asia between 2004 and 2017 were divided into a development (DS; n = 1558) and validation set (VS; n = 801) by random sampling of participating centres. The Early Recurrence Score (ERS) was generated using variables associated with 2-year recurrence in the DS and validated in the VS. RESULTS: Variables associated with 2-year recurrence in the DS were (with associated points) alpha-fetoprotein (<10 ng/mL:0; 10-100: 2; >100: 3), size of largest nodule (≥40 mm: 1), multifocality (yes: 2), satellite nodules (yes: 2), vascular invasion (yes: 1) and surgical margin (positive R1: 2). The sum of points provided a score ranging from 0 to 11, allowing stratification into four levels of 2-year recurrence risk (Wolbers' C-indices 66.8% DS and 68.4% VS), with excellent calibration according to risk categories. Wolber's and Harrell's C-indices apparent values were systematically higher for ERS when compared to Early Recurrence After Surgery for Liver tumour post-operative model to predict time to early recurrence or recurrence-free survival. CONCLUSIONS: ERS is a user-friendly staging system identifying four levels of early recurrence risk after SR and a robust tool to design personalised surveillance strategies and adjuvant therapy trials.

Multi-visceral resection for left-sided pancreatic ductal adenocarcinoma: a multicenter retrospective analysis from European countries.

BACKGROUND: Due to delayed diagnosis and a lower surgical indication rate, left-sided pancreatic ductal adenocarcinoma (PDAC) is often associated with a poor prognosis in comparison to pancreatic head tumors. Multi-visceral resections (MVR) associated with distal pancreatectomy could be proposed for patients presenting with locally infiltrating disease. METHODS: We retrospectively analyzed a multi-centric cohort of left-sided PDAC patients operated on from 2009 to 2020. Thirteen European high-volume HPB centers participated in this study. We analyzed patients who underwent distal pancreatectomy (DP) associated with MVR and compared them to standard DP patients. RESULTS: Among 258 patients treated curatively for PDAC of the body and tail, 28 patients successfully underwent MVR. A longer operative time was observed in the MVR group (295 min +/- 74 vs. 250 min +/- 96, p= 0.248). The post-operative complication rate was comparable between the two groups (46.4% in the MVR group vs. 62.2% in the control group, p= 0.108). The incidence of positive margin (R1) was similar between the two groups (28.6% vs. 26.6%; p=0.827). After a median follow-up of 25 (9-111) months, overall survival was comparable between the two groups (p= 0.519). CONCLUSIONS: Multi-visceral resection in left-sided pancreatic ductal adenocarcinoma is safe and feasible and should be considered in selected cases as it seems to provide acceptable surgical and oncological outcomes.

Prognostic impact of splenic vessel involvement and tumor size in distal pancreatectomy for adenocarcinoma: a retrospective multicentric cohort study.

PURPOSE: Splenic vessel involvement occurs frequently in pancreatic ductal adenocarcinoma (PDAC) of the body and the tail (B/T) but the impact on survival is unknown. We assessed the influence of radiological and pathologic involvement of splenic artery (p-SA +) and vein (p-SV +) on patient outcomes after distal pancreatectomy (DP) for PDAC. METHODS: From 2013 to 2019, all DP for PDAC in five centers were included. Factors associated with overall (OS) and disease-free (DFS) survival were identified. RESULTS: Among the 76 patients included, 5 (6.6%) had p-SA + only, 11 (14.5%) had p-SV + only, and 24 (31.6%) had both p-SA + and p-SV + . The preoperative CT-scan accuracy to predict p-SV + and p-SA + was high (sensitivity: 91.4% and 82.8%, respectively; negative predictive value: 89.7% and 88.3%, respectively). The 5-year OS and DFS rates were 3.9% and 8.3%, respectively. Multivariate analysis identified splenic vessel involvement (i.e., p-SA + or p-SV + , or both p-SA + and p-SV +) as the only independent factor influencing DFS (HR 4.04; 95% CI [1.22-13.44], p = 0.023). Tumor size ≥ 30 mm was the only independent factor influencing OS (HR 4.04; 95% CI [1.26-12.95], p = 0.019) and was associated with a high risk of p-SA + (p = 0.001) and p-SV + (p < 0.001). CONCLUSION: Tumor size ≥ 30 mm and splenic vessel involvement occurred in more than half of the patients who underwent DP for PDAC and had negative impact on long-term survival. Preoperative CT-scan was reliable to identify splenic vessel involvement in B/T PDAC. Large tumor size and radiological splenic vessel involvement could be taken into account to propose a neoadjuvant treatment.

Emergency computed tomography evaluation of caustic ingestion.

Computed tomography (CT) is used increasingly for the emergency assessment of caustic injuries and the need for emergency endoscopy has been challenged. The study evaluates outcomes of caustic ingestion in the modern era and the feasibility of abandoning emergency endoscopy. Between 2013 and 2019, 414 patients (197 men, median age 42 years) were admitted for caustic ingestion. Emergency and long-term outcomes of patients managed by CT and endoscopy (n = 120) and by CT alone (n = 294) were compared. Propensity score-based analysis was performed to limit bias of between-group comparison. A standard mortality ratio (SMR) was used to compare the observed mortality with the expected mortality in the general French population. Complications occurred in 97 (23%) patients and 17 (4.1%) patients died within 90 days of ingestion. Among 359 patients who underwent nonoperative management, 51 (14%) experienced complications and 7 (2%) died. Of 55 patients who underwent emergency surgery, 46 (84%) experienced complications and 10 (18%) died. The SMR was 8.4 for whole cohort, 5.5 after nonoperative management, and 19.3 after emergency surgery. On multivariate analysis, intentional ingestion (P < 0.016), age (P < 0.0001) and the CT grade of esophageal injuries (P < 0.0001) were independent predictors of survival. The CT grade of esophageal injuries was the only independent predictor of success (P < 0.0001). Crude and propensity match analysis showed similar survival in patients managed with and without endoscopy. CT evaluation alone can be safely used for the emergency management of caustic ingestion.

Quality of Life After Caustic Ingestion.

OBJECTIVE: The aim of the study was to evaluate long-term QOL after caustic ingestion. BACKGROUND: Caustic ingestion strongly affects patient's QOL but data on the topic is scarce in the literature. METHODS: QOL evaluation was conducted in survivors from a large cohort of patients with caustic injuries. QOL was assessed using the EORTC QLQ-OG25 module, the SF12v2 score, and the hospital anxiety and depression scale questionnaire. One hundred thirty-four patients (59 men, median age 43) completed the survey; 72 (54%) patients underwent emergency digestive resection and in 99 (74%) patients underwent esophageal reconstruction. Results of QOL questionnaires were compared to average values determined in healthy volunteers and in patients with esophageal cancers. RESULTS: The median QLQ-OG25 score was 44 (34, 62) and values were significantly lower when compared to a normal population (P < 0.0001). SF12v2 scores were significantly inferior to those expected in a normal population on both the physical component summary (PCS) (43.3 ±â€Š10.8; P < 0.0001) and the mental component summary (44 ±â€Š9.7; P < 0.0001) scales. Emergency esophageal resection was significantly associated with higher QLQ-OG25 scores (P < 0.0001), but not with mental component summary (P = 0.3), PCS (P = 0.76), HAD anxiety (P = 0.95), and HAD depression scores (P = 0.59); results were similar after extended emergency resection. When compared to esophagocoloplasty alone, pharyngeal reconstruction had a significant negative impact on QLQ-OG25 (P < 0.0001), PCS (P = 0.01), and HAD depression (P = 0.0008) scores. CONCLUSIONS: QOL is significantly impaired after caustic ingestion. QOL issues should not influence the emergency surgical strategy but deserve discussion before esophageal reconstruction for caustic injuries.

The Oncologic Impact of Pancreatic Fistula After Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma of the Body and the Tail: A Multicenter Retrospective Cohort Analysis.

OBJECTIVES: The aim of this study was to assess the impact of clinically relevant postoperative pancreatic fistula (CR-POPF) on patient disease-specific survival and recurrence after curative distal pancreatectomy (DP) for pancreatic cancer. DESIGN: This was a retrospective case-control analysis. METHODS: We examined the data of adult patients with a diagnosis of pancreatic ductal adenocarcinoma (PDAC) of the body and tail of the pancreas undergoing curative DP, over a 10-year period in 12 European surgical departments, from a prospectively implemented database. RESULTS: Among the 382 included patients, 283 met the strict inclusion criteria; 139 were males (49.1%) and the median age of the entire population was 70 years (range 37-88). A total of 121 POPFs were observed (42.8%), 42 (14.9%) of which were CR-POPFs. The median follow-up period was 24 months (range 3-120). Although poorer in the POPF group, overall survival (OS) and disease-free survival (DFS) did not differ significantly between patients with and without CR-POPF (p = 0.224 and p = 0.165, respectively). CR-POPF was not significantly associated with local or peritoneal recurrence (p = 0.559 and p = 0.302, respectively). A smaller percentage of patients benefited from adjuvant chemotherapy after POPF (76.2% vs. 83.8%), but the difference was not significant (p = 0.228). CONCLUSIONS: CR-POPF is a major complication after DP but it did not affect the postoperative therapeutic path or long-term oncologic outcomes. CR-POPF was not a predictive factor for disease recurrence and was not associated with an increased incidence of peritoneal or local relapse. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT04348084.

Delayed Postoperative Hemorrhage Complicating Major Supramesocolic Surgery Management and Outcomes.

BACKGROUND: The place of surgery and interventional radiology in the management of delayed (> 24 h) hemorrhage (DHR) complicating supramesocolic surgery is still to define. The aim of the study was to evaluate outcomes of DHR using a combined multimodal strategy. METHODS: Between 2005 and 2019, 57 patients (median age 64 years) experienced 86 DHR episodes after pancreatic resection (n = 26), liver transplantation (n = 24) and other (n = 7). Hemodynamically stable patients underwent computed tomography evaluation followed by interventional radiology (IR) treatment (stenting and/or embolization) or surveillance. Hemodynamically unstable patients were offered upfront surgery. Failure to identify the leak was managed by either prophylactic stenting/embolization of the most likely bleeding source or surveillance. RESULTS: Mortality was 32% (n = 18). Bleeding recurrence occurred in 22 patients (39%) and was multiple in 7 (12%). Sentinel bleeding was recorded in 77 (81%) of episodes, and the bleeding source could not be identified in 26 (30%). Failure to control bleeding was recorded in 9 (28%) of 32 episodes managed by surgery and 4 (11%) of 41 episodes managed by IR (p = 0.14). Recurrence was similar after stenting and embolization (n = 4/18, 22% vs n = 8/26, 31%, p = 0.75) of the bleeding source. Recurrence was significantly lower after prophylactic IR management than surveillance of an unidentified bleeding source (n = 2/10, 20% vs. n = 11/16, 69%, p = 0.042). CONCLUSION: IR management should be favored for the treatment of DHR in hemodynamically stable patients. Prophylactic IR management of an unidentified leak decreases recurrence risks.

Delayed post-pancreatectomy hemorrhage and bleeding recurrence after percutaneous endovascular treatment: risk factors from a bi-centric study of 307 consecutive patients.

PURPOSE: Delayed post-pancreatectomy hemorrhage (PPH) is still one of the most dreaded complications after pancreatic surgery. Its management is now focused on percutaneous endovascular treatments (PETs). METHODS: Between 2013 and 2019, 307 patients underwent pancreatic resection. The first endpoint of this study was to determine predictive factors of delayed PPH. The second endpoint was to describe the management of intra-abdominal abscesses (IAA). The third endpoint was to identify risk factors of bleeding recurrence after PET. Patients were divided into two cohorts: A retrospective analysis was performed ("cohort 1," "learning set") to highlight predictive factors of delayed PPH. Then, we validated it on a prospective maintained cohort, analyzed retrospectively ("cohort 2," "validation set"). Second and third endpoints studies were made on the entire cohort. RESULTS: In cohort 1, including 180 patients, 24 experienced delayed PPH. Multivariate analysis revealed that POPF diagnosis on postoperative day (POD) 3 (p=0.004) and IAA (p=0.001) were independent predictive factors of delayed PPH. In cohort 2, association of POPF diagnosis on POD 3 and IAA was strongly associated with delayed PPH (area under the curve [AUC] 0.80; 95% confidence interval [CI] [0.59-0.94]; p=0.003). Concerning our second endpoint, delayed PPH occurred less frequently in patients who underwent postoperative drainage procedure than in patients without IAA drainage (p=0.002). Concerning our third endpoint, a higher body mass index (BMI) (p=0.027), occurrence of postoperative IAA (p=0.030), and undrained IAA (p=0.011) were associated with bleeding recurrence after the first PET procedure. CONCLUSION: POPF diagnosis on POD 3 and intra-abdominal abscesses are independent predictive factors of delayed PPH. Therefore, patients presenting an insufficiently drained POPF leading to intra-abdominal abscess after pancreatic surgery should be considered as a high-risk situation of delayed PPH. High BMI, occurrence of postoperative IAA, and undrained IAA were associated with recurrence of bleeding after PET.

[Primary liposarcomas of the digestive tract: Diversity of clinicopathological presentations and diagnostic challenges]. / Liposarcomes primitifs du tube digestif : diversité des présentations clinicopathologiques et challenges diagnostiques.

Sarcomas are rare tumours that represent less than 1% of all malignant tumours in adults. Liposarcomas are among the most common malignant mesenchymal tumours. They are preferentially located in the limbs and the retroperitoneum. Liposarcomas primarily arising in the digestive tract are exceptional with a few cases reported in the literature. Their clinical presentation is variable and the symptoms are not specific. Anatomopathological examination remains the gold standard for the diagnosis and the classification of these tumours, which are divided into 5 histological types according to the 5th edition of the WHO classification of soft tissue tumours. We report two observations of unusual digestive liposarcomas, located in the oesophagus and the colon, emphasizing the variability of the diagnostic challenges, depending on the clinical presentation, the histological type and the analysed material.

Emergency Computed Tomography Predicts Caustic Esophageal Stricture Formation.

BACKGROUND: Endoscopy is the best predictor of stricture formation after caustic ingestion. OBJECTIVE: Our aim was to compare the accuracy of emergency computed tomography (CT) and endoscopy in predicting risks of esophageal stricture. METHODS: We describe a CT classification of esophageal caustic injuries: Grade I show normal esophagus; Grade IIa display internal enhancement of the esophageal mucosa and enhancement of the outer wall conferring a "target" aspect; Grade IIb present as a fine rim of external esophageal wall enhancement. In 152 patients (56 males, median age 45) who underwent esophageal preservation after caustic ingestion we compared the accuracy of the CT and endoscopic (Zargar) classifications in predicting esophageal stricture. RESULTS: On endoscopy esophageal injuries were classified as grade 1 (n = 50; 33%), grade 2a (n = 11; 7%), grade 2b (n = 19; 13%), grade 3a (n = 14; 9%), and grade 3b (n = 58; 38%). On CT, 47 (31%) patients had grade I, 47 (31%) had grade IIa and 58 (38%) had grade IIb esophageal injuries. Fifty-six (37%) patients developed esophageal strictures. The risk of esophageal stricture formation was 0%, 17%, and 83%, for grade I, IIa, and IIb CT injuries and 0, 0, 28, 50, and 76% for endoscopic grade 1, 2a, 2b, and 3a and 3b injuries, respectively. ROC curve analysis at 120 days after ingestion showed that CT outperformed endoscopy in predicting stricture formation (AUC: 85.1 [95% CI, 74.9-95.3] vs 77.8 [95% CI, 66.5-89.0], P = 0.047) and did just as well as a combined CT-endoscopy algorithm (AUC: 85.8 [95% CI, 76.5-95.0] vs 85.1 [95% CI, 74.9-95.3], P = 0.73). CONCLUSION: Emergency CT outperforms endoscopy in predicting esophageal stricture formation after caustic ingestion. Emergency endoscopy evaluation after caustic ingestion is not indispensable.

Preoperative Biliary Stenting and Major Morbidity After Pancreatoduodenectomy: Does Elapsed Time Matter?: The FRAGERITA Study Group.

OBJECTIVE: To analyze possible associations between the duration of stent placement before surgery and the occurrence and severity of postoperative complications after pancreatoduodenectomy (PD). BACKGROUND: The effect of preoperative stent duration on postoperative outcomes after PD has not been investigated. METHODS: From 2013 to 2016, patients who underwent PD for any reasons after biliary stent placement at 5 European academic centers were analyzed from prospectively maintained databases. The primary aim was to investigate the association between the duration of preoperative biliary stenting and postoperative morbidity. Patients were stratified by stent duration into 3 groups: short (<4 weeks), intermediate (4-8 weeks), and long (≥8 weeks). RESULTS: In all, 312 patients were analyzed. The median time from stent placement to surgery was 37 days (2-559 days), and most operations were performed for pancreatic cancer (67.6%). Morbidity and mortality rates were 56.0% and 2.6%, respectively. Patients in the short group (n = 106) experienced a higher rate of major morbidity (43.4% vs 20.0% vs 24.2%; P < 0.001), biliary fistulae (13.2% vs 4.3% vs 5.5%; P = 0.031), and length of hospital stay [16 (10-52) days vs 12 (8-35) days vs 12 (8-43) days; P = 0.025]. A multivariate adjusted model identified the short stent duration as an independent risk factor for major complications (odds ratio 2.64, 95% confidence interval 1.23-5.67, P = 0.013). CONCLUSIONS: When jaundice treatment cannot be avoided, delaying surgery up to 1 month after biliary stenting may reduce major morbidity, procedure-related complications, and length of hospital stay.

Caustic ingestion.

Corrosive ingestion is a rare but potentially devastating event and, despite the availability of effective preventive public health strategies, injuries continue to occur. Most clinicians have limited personal experience and rely on guidelines; however, uncertainty persists about best clinical practice. Ingestions range from mild cases with no injury to severe cases with full thickness necrosis of the oesophagus and stomach. CT scan is superior to traditional endoscopy for stratification of patients to emergency resection or observation. Oesophageal stricture is a common consequence of ingestion and newer stents show some promise; however, the place of endoscopic stenting for corrosive strictures is yet to be defined. We summarise the evidence to provide a plan for managing these potentially life-threatening injuries and discuss the areas where further research is required to improve outcomes.

Damage Control Surgery for Non-traumatic Abdominal Emergencies.

BACKGROUND: Damage control surgery (DCS) was a major paradigm change in the management of critically ill trauma patients and has gradually expanded in the general surgery arena, but data in this setting are still scarce. The study aim was to evaluate outcomes of DCS in patients with general surgery emergencies. METHODS: Between 2005 and 2015, 164 patients (104 men, age 66) underwent DCS for non-traumatic abdominal emergencies. The decision to perform DCS was triggered by the presence of at least one trauma DCS criterion: hypotension (<70 mmHg), hypothermia (<35 °C), acidosis (pH < 7.25), coagulopathy (INR ≥ 1.7) and massive (>5 RBC) transfusion. Statistical tests were performed to identify risk factors for operative mortality. Observed outcomes were compared to those predicted by commonly employed scores (APACHE II, POSSUM, P-POSSUM, SAPS II). RESULTS: DCS was performed for acute mesenteric ischemia (n = 68), peritonitis (n = 44), pancreatitis (n = 28), bleeding (n = 14) and other (n = 10). Abdominal compartment syndrome was associated in 52 patients (32%). Seventy-four (45%) patients died and 150 patients (91%) experienced complications. On multivariate analysis, age (p = 0.018) and INR ≥ 1.7 (p = 0.001) were independent predictors of mortality. Mortality was 24% (13/55), 48% (22/46) and 62% (39/63) in patients with one, two and ≥3 DCS criteria, respectively. Comparison of observed and score-predicted mortality suggested DCS use resulted in significant survival benefit of the whole cohort and of patients with pancreatitis and postoperative peritonitis. CONCLUSIONS: DCS can be lifesaving in critically ill patients with general surgery emergencies. Patients with peritonitis and acute pancreatitis are those who benefit most of the DCS approach.

Internal biliary stenting in liver transplantation.

PURPOSE: Internal biliary stenting (IBS) was reported to decrease biliary complications after liver transplantation (LT) but data in literature is scarce. The aim of the present study was to evaluate our experience with end-to-end choledoco-choledocostomy during liver transplantation with special focus on the influence of IBS on patient and biliary outcomes. METHODS: Between 2009 and 2013, 175 patients underwent deceased donor LT with end-to-end choledoco-choledocostomy and were included in the study. Supra-papillary silastic stent was inserted in 67 patients (38%) with small-size (< 5 mm) bile ducts (recipient or donor). Endoscopic retrograde cholangiopancreatography (ERCP) was scheduled for IBS removal, 6 months after LT. Operative outcomes and survival of patients who received internal stenting (IBS group) were compared with those of patients who did not (no-IBS group). Risk factors for biliary anastomotic complications were identified. RESULTS: Ten patients died (6%) and 104 (59%) experienced postoperative complications. Five-year patient and graft survival rates were 77 and 74%, respectively. Biliary complications were recorded in 61 patients (35%) and were significantly decreased by IBS insertion (p = 0.0003). Anastomotic fistulas occurred in 23 patients (13%) and stenoses in 44 patients (25%). On multivariate analysis, high preoperative MELD scores (p = 0.02) and hepatic artery thrombosis (p < 0.0001) were predictors of fistula; absence of IBS was associated with both fistula (p = 0.014) and stricture (p = 0.003) formation. CONCLUSIONS: IBS insertion during LT decreases anastomotic complication.

Tracheobronchial Necrosis After Caustic Ingestion.

OBJECTIVE: The aim of this study was to describe the management and outcome of tracheobronchial necrosis (TBN) after caustic ingestion. BACKGROUND: Emergency pulmonary patch repair has been reported to be lifesaving in patients with caustic TBN. METHODS: Patients who underwent management of caustic TBN between 1989 and 2013, were included. TBN was defined as early if present on admission and late if occurring thereafter. Operative outcomes, long-term survival, and functional outcomes were compared with those of 269 patients without TBN who underwent esophagectomy for caustic injuries. RESULTS: Twenty patients were included (10 men; median age = 39 years). Early TBN was detected in 14 patients, and late TBN occurred in 7 patients, 8 days (range:: 6-10 days) after admission. TBN involved the left bronchus (n = 17; 85%), the carina (n = 10; 50%), the supracarinal trachea (n = 9; 45%), the right bronchus (n = 4; 20%), and the cervical trachea (n = 3; 15%). Seventeen patients underwent esophagogastrectomy, 2 underwent esophagectomy, and in 1 patient, resection was eventually abandoned. Pulmonary patch repair was performed in 16 patients (80%). Nine patients (45%) died and morbidity was 100%. In univariate analysis, late TBN (P = 0.017) and acid ingestion (P = 0.002) were predictors of mortality. All survivors underwent restoring colopharyngoplasty. Five-year survival (28%) and functional success (25%) rates were significantly impaired when compared with esophagectomy patients without TBN. CONCLUSIONS: TBN is one of the most devastating complications of caustic ingestion. Pulmonary patch repair is technically simple and can be lifesaving in this difficult situation.

Computed Tomography Evaluation of Esophagogastric Necrosis After Caustic Ingestion.

BACKGROUND: Endoscopy is the standard of care for emergency patient evaluation after caustic ingestion. However, the inaccuracy of endoscopy in determining the depth of intramural necrosis may lead to inappropriate decision-making with devastating consequences. Our aim was to evaluate the use of computed tomography (CT) for the emergency diagnostic workup of patients with caustic injuries. METHODS: In a prospective study, we used a combined endoscopy-CT decision-making algorithm. The primary outcome was pathology-confirmed digestive necrosis. The respective utility of CT and endoscopy in the decision-making process were compared. Transmural endoscopic necrosis was defined as grade 3b injuries; signs of transmural CT necrosis included absence of postcontrast gastric/ esophageal-wall enhancement, esophageal-wall blurring, and periesophageal-fat blurring. RESULTS: We included 120 patients (59 men, median age 44 years). Emergency surgery was performed in 24 patients (20%) and digestive resection was completed in 16. Three patients (3%) died and 28 patients (23%) experienced complications. Pathology revealed transmural necrosis in 9/11 esophagectomy and 16/16 gastrectomy specimens. Severe oropharyngeal injuries (P = 0.015), increased levels of blood lactate (P = 0.007), alanine aminotransferase (P = 0.027), bilirubin (P = 0.005), and low platelet counts (P > 0.0001) were predictive of digestive necrosis. Decision-making relying on CT alone or on a combined CT-endoscopy algorithm was similar and would have spared 19 unnecessary esophagectomies and 16 explorative laparotomies compared with an endoscopy-alone algorithm. Endoscopy did never rectify a wrong CT decision. CONCLUSIONS: Emergency decision-making after caustic injuries can rely on CT alone.