Adjuvant chemotherapy omission after pancreatic cancer resection: a French nationwide study.

BACKGROUND: Adjuvant chemotherapy (AC) improves the prognosis after pancreatic ductal adenocarcinoma (PDAC) resection. However, previous studies have shown that a large proportion of patients do not receive or complete AC. This national study examined the risk factors for the omission or interruption of AC. METHODS: Data of all patients who underwent pancreatic surgery for PDAC in France between January 2012 and December 2017 were extracted from the French National Administrative Database. We considered "omission of adjuvant chemotherapy" (OAC) all patients who failed to receive any course of gemcitabine within 12 postoperative weeks and "interruption of AC" (IAC) was defined as less than 18 courses of AC. RESULTS: A total of 11 599 patients were included in this study. Pancreaticoduodenectomy was the most common procedure (76.3%), and 31% of the patients experienced major postoperative complications. OACs and IACs affected 42% and 68% of the patients, respectively. Ultimately, only 18.6% of the cohort completed AC. Patients who underwent surgery in a high-volume centers were less affected by postoperative complications, with no impact on the likelihood of receiving AC. Multivariate analysis showed that age ≥ 80 years, Charlson comorbidity index (CCI) ≥ 4, and major complications were associated with OAC (OR = 2.19; CI95%[1.79-2.68]; OR = 1.75; CI95%[1.41-2.18] and OR = 2.37; CI95%[2.15-2.62] respectively). Moreover, age ≥ 80 years and CCI 2-3 or ≥ 4 were also independent risk factors for IAC (OR = 1.54, CI95%[1.1-2.15]; OR = 1.43, CI95%[1.21-1.68]; OR = 1.47, CI95%[1.02-2.12], respectively). CONCLUSION: Sequence surgery followed by chemotherapy is associated with a high dropout rate, especially in octogenarian and comorbid patients.

Epidemiology of congenital heart defects in France from 2013 to 2022 using the PMSI-MCO (French Medical Information System Program in Medicine, Surgery, and Obstetrics) database.

BACKGROUND: Congenital heart defects are common and occur in approximately 0.9% of births. In France, the registries cover approximately 20% of the population but not the entirety of France; therefore, we aimed to update the incidence data for congenital heart defects in France from 2013 to 2022 using the medico-administrative database PMSI-MCO (French Medical Information System Program in Medicine, Surgery, and Obstetrics). We aimed to compare the frequency of risk factors in a population with congenital heart defects and a reference population. METHODS: From 2013 to 2022, we included children aged < 3 years diagnosed with congenital heart defects according to the International Classification of Diseases, 10th Revision, in the PMSI-MCO database. We compared them with a population without congenital defects on several medical data items (e.g., parity, gemellarity, and mortality rate). Bivariate and multivariate analyses compared children with congenital heart defects and children without congenital malformation. RESULTS: We identified 83,879 children with congenital heart defects in France from 2013 to 2022 in the PMSI-MCO database and 7,739,840 children without such defects, including 7,218,952 without any congenital defects. We observed more deaths (7.49% vs. 0.68%, d = 0.59) and more twinning (8.67% vs. 1.23%, d = 0.35) among children with congenital heart defects. Multivariate analysis revealed an increased risk of congenital heart defects in male individuals (OR [odds ratio] 1.056, 95% CI [confidence interval] [1.039-1.076]) and cases of medically assisted reproduction (OR 1.115, 95% CI [1.045-1.189]) and a reduced risk in the case of multiparity (OR 0.921, 95% CI [0.905-0.938]). CONCLUSIONS: According to the PMSI-MCO database, the incidence of congenital heart defects in France from 2013 to 2022 is 1% of births. Congenital heart defects are more frequent in cases of prematurity, twinning, primiparity, male sex, and maternal age > 40 years.

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

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

Risk-Benefit Balance of Simultaneous Gastric Bypass or Sleeve Gastrectomy and Concomitant Cholecystectomy: A Comprehensive Nationwide Cohort of 289,627 Patients.

OBJECTIVE: To assess the relevance of concomitant laparoscopic metabolic bariatric surgery (MBS) and cholecystectomy. BACKGROUND: Because of the massive weight loss it induces, MBS is associated with an increase in the frequency of gallstones. However, no consensus yet exists on the risk-to-benefit ratio of a concomitant cholecystectomy (CC) during MBS to prevent long-term biliary complications. METHODS: This nationwide retrospective cohort research was conducted in 2 parts using information from a national administrative database (PMSI). The 90-day morbidity of MBS with or without CC was first compared in a matched trial (propensity score). Second, we observed medium-term biliary complication following MBS when no CC had been performed during MBS up to 9 years after MBS (minimum 18 months). RESULTS: Between 2013 and 2020, 289,627 patients had a sleeve gastrectomy (SG: 70%) or a gastric bypass (GBP: 30%). The principal indications of CC were symptomatic cholelithiasis (79.5%) or acute cholecystitis (3.6%). Prophylactic CC occurred only in 15.5% of the cases. In our matched-group analysis, we included 9323 patients in each arm. The complication rate at day 90 after surgery was greater in the CC arm [odds ratio=1.3 (1.2-1.5), P <0.001], independently of the reason of the CC. At 18 months, there was a 0.1% risk of symptomatic gallstone migration and a 0.08% risk of biliary pancreatitis. At 9 years, 20.5±0.52% of patients underwent an interval cholecystectomy. The likelihood of interval cholecystectomy decreased from 5.4% per year to 1.7% per year after the first 18 months the whole cohort, risk at 18 months of symptomatic gallstone migration was 0.1%, of pancreatitis 0.08%, and of angiocholitis 0.1%. CONCLUSION: CC during SG and GBP should be avoided. In the case of asymptomatic gallstones after MBS, prophylactic cholecystectomy should not be recommended.

Failure to rescue following proctectomy for rectal cancer: the additional benefit of laparoscopic approach in a nationwide observational study of 44,536 patients.

BACKGROUND: There is growing evidence that failure to rescue (FTR) is an important factor of postoperative mortality (POM) after rectal cancer surgery and surgical approach modified post-operative outcomes. However, the impact of laparoscopy on FTR after proctectomy for rectal cancer remains unknown. The aim of this study was to compare the rates of postoperative complications and FTR after laparoscopy vs open proctectomy for cancer. METHODS: All patients who underwent proctectomy for rectal cancer between 2012 and 2016 were included. FTR was defined as the 90-day POM rate among patients with major complications. Outcomes of patients undergoing open or laparoscopic rectal cancer surgery were compared after 1:1 propensity score matching by year of surgery, hospital volume, sex, age, Charlson score, neoadjuvant chemotherapy, tumor localization and type of anastomosis. RESULTS: Overall, 44,536 patients who underwent proctectomy were included, 7043 of whom (15.8%) developed major complications. The rates of major complications, POM and FTR were significantly higher in open compared to laparoscopic procedure (major complications: 19.2% vs 13.7%, p < 0.001; POM: 5.4% vs 2.3%, p < 0.001; FTR: 13.6% vs 8.3%, p < 0.001; respectively). After matching, open and laparoscopic groups were comparable. Multivariate analysis showed that age, Charlson score, sphincter-preserving procedure and surgical approach were predictive factors for FTR. Open proctectomy was found to be a risk factor for FTR (OR 1.342, IC95% [1.066; 1.689], p = 0.012) compared to laparoscopic procedure. CONCLUSION: When complications occurred, patients operated on by open proctectomy were more likely to die.

Partial Versus Total Thyroidectomy: What Influences Most Surgeons' Decision? Analysis of a Nationwide Cohort of 375,810 Patients Over 10 Years.

National and international guidelines about thyroid surgery seem to be moving more and more towards less radical surgical procedures but everyday practice does not seem to always align with them. We describe for the first time the role of non-surgical parameters in the surgeon's choice for thyroid surgery. OBJECTIVE: The ain of this study was to describe thyroid surgery and to identify the factors leading to either a total or a partial thyroidectomy regardless of the severity of the thyroid disease. SUMMARY BACKGROUND DATA: National and international guidelines about thyroid surgery seem to be moving more and more toward less radical surgical procedures but everyday practice does not seem to always align with them. METHODS: We based this nationwide retrospective cohort study on a national database that compiles discharge abstracts for every admission for thyroidectomy to French acute healthcare facilities (PMSI database 2010 to 2019). RESULTS: In this study, 375,810 patients (male: 23%; age = 53 ±â€Š15 years) had a thyroidectomy (partial: 28%) for cancer (17%), hyperthyroidism (16%), nonfunctioning goiter (64%), or other (3%). We noticed a global trend toward more partial thyroidectomy (P < 0.001) with a significant increase in the proportion of lobectomy in the post-ATA recommendations' period (P < 0.001) as well as in the "French Levothyrox crisis" period, in which we saw an unexpected rise of adverse events notifications associated with the marketing of a new formula of Levothyrox (P < 0.001) amid widespread media coverage. In a multivariate analysis, we also identified that complete resection was more frequently performed in centers with a caseload >40/year [P < 0.001, odds ratio (OR) = 1.48], for obese patients (body mass index >30 kg/m2; P < 0.001, OR = 1.42), and according to the indication of surgery (OR benign = 1, OR cancer = 2.25, OR hyperthyroidism = 4.13). CONCLUSION: We describe for the first time the role of non-surgical parameters in the surgeon's choice for thyroid surgery.

Referring Patients to Expert Centers After Pancreatectomy Is Too Late to Improve Outcome. Inter-hospital Transfer Analysis in Nationwide Study of 19,938 Patients.

OBJECTIVES: We aimed to analyze the outcomes of interhospital transfer (IHT) patients after pancreatectomy, describe the characteristics of transferring hospitals, and determine the risk factors of transfer and mortality in IHT patients. BACKGROUND: Implementation of the centralization process is complex and currently unrealized in France. Alternatively, centralization of patients with postoperative complications to high volume centers could reduce postoperative mortality (POM) and failure to rescue (FTR). METHODS: All patients undergoing pancreatectomy for cancer between 2012 and 2018 were included. Hospitals' and patients' characteristics were analyzed to determine predictive factors for transfer and FTR. POM was defined as death occurring during the hospital stay and FTR as POM rate among patients with major complications. RESULTS: Overall, 19,938 patients who underwent pancreatectomy were included, 1164 (5.8%) of whom were transferred. IHT patients were mostly originated from low volume hospitals (60.3% vs 39.7%), from facilities without intensive care unit (46.9% vs 22.4%) or interventional radiology (22.8% vs 12.8%). Among IHT patients, 51% underwent reoperation before transfer and 34.9% experienced hemorrhage complications. The POM was 5.2% and varied significantly between transfer and nontransfer patients (13.3% vs 4.7%, P < 0.001). Patients who experienced major complications after pancreatectomy in low volume hospitals had greater odds of being transferred (Odds Ratio (OR) = 2.46, confidence intervals (CI)95%[1.734; 3.516], P < 0.001). Also, transfer (OR = 2.17, CI95%[1.814; 2.709], P < 0.001) and especially transfer after pancreatectomy in low volume centers (OR = 3.76, CI95%[2.83; 5.01], P < 0.001) were associated with increased FTR rates. CONCLUSIONS: Transfers after pancreatectomy were associated with high rates of FTR, especially for patients undergoing surgery in low volume hospitals. Local expertise, resources, and volume of hospitals are mandatory to provide appropriate care after pancreatectomy.

Risk Factors of Redo Surgery After Unilateral Focused Parathyroidectomy: Conclusions From a Comprehensive Nationwide Database of 13,247 Interventions Over 6 Years.

BACKGROUND: Surgical removal of hyperfunctional parathyroid gland is the definitive treatment for primary hyperparathyroidism (pHPT). Postoperative follow-up shows variability in persistent/recurrent disease rate throughout different centers. OBJECTIVE: To evaluate the incidence of redo surgery after targeted parathyroidectomy for pHPT. METHODS: We performed a nationwide retrospective cohort study on the "Programme de Medicalisation des Systemes d'Information," the French administrative database that collects information on all healthcare facilities' discharges. We extracted data from 2009 to 2018 for all patients who underwent parathyroidectomy for pHPT between January 2011 to December 2016. The primary outcome was the reoperation rate within 2 years since first surgery. Patients who had a first attempt of surgery within the previous 24 months, familial hyperparathyroidism, multiglandular disease, and renal failure were excluded. Results were adjusted according to sex and the Elixhauser Comorbidity Index. Operative volume thresholds to define high-volume centers were achieved by the Chi-Squared Automatic Interaction Detector method. RESULTS: In the study period, 13,247 patients (median age 63, F/M=3.6) had a focused parathyroidectomy by open (88.7%) or endoscopic approach. Need of remedial surgery was 2.8% at 2 years. In multivariate analysis, factors predicting redo surgery were: cardiac history (P=0.008), obesity (P=0.048), endoscopic approach (P=0.005), and low-volume center (P<0.001). We evaluated that an annual caseload of 31 parathyroidectomies was the best threshold to discriminate high-volume centers and carries the lowest morbidity/failure rate. CONCLUSION: Although focused parathyroidectomy represents a standardized operation, cure rate is strongly associated with annual hospital caseload, type of procedure (endoscopic), and patients' features (obesity, cardiac history). Patients with risk factors for redo surgery should be considered for an open surgery in a high-volume center.

Should all pancreatic surgery be centralized regardless of patients' comorbidity?

BACKGROUND: It remains to be established whether centralization to high volume centers is essential for all patients undergoing pancreatic surgery. The aims of this study were to identify the optimal cut-off volume to optimize patient outcomes and to determine if patient comorbidity affected the volume-outcome relationship. METHODS: Patients undergoing pancreatectomy from 2012 to 2015 were retrospectively identified (n = 12 333) in the French nationwide database. The 90-day Post-Operative Mortality (POM) was analyzed according to hospital volume of pancreatectomy (very low:<10, Low:10-19, High:20-49 and very high:≥50 resections/year) and Charlson Comorbidity Index (ChCI). RESULTS: The overall POM was 6.9%. The cut-off of 20 pancreatic resections per year was identified as predictor of POM. Compared to high volume centers, POM was significantly higher in low and very low volume centers whatever the ChCl. Regarding surgical procedures, there was a significant decrease in POM with increasing hospital volume only after pancreaticoduodenectomy regardless of the ChCl. On multivariable analysis, low and very low volume centers were independently associated with increased mortality rates. CONCLUSION: The optimal cut-off of annual caseload was 20 pancreatic resections. POM following pancreaticoduodenectomy is high in low and very low volume centers independently of ChCl, suggesting that this procedure should be centralized.

Adrenalectomy Risk Score: An Original Preoperative Surgical Scoring System to Reduce Mortality and Morbidity After Adrenalectomy.

OBJECTIVE: To explore the determinants of postoperative outcomes of adrenal surgery in order to build a proposition for healthcare improvement. SUMMARY OF BACKGROUND DATA: Adrenalectomy is the recommended treatment for many benign and malignant adrenal diseases. Postoperative outcomes vary widely in the literature and their determinants remain ill-defined. METHODS: We based this retrospective cohort study on the "Programme de médicalisation des systèmes d'information" (PMSI), a national database that compiles discharge abstracts for every admission to French acute health care facilities. Diagnoses identified during the admission were coded according to the French adaptation of the 10th edition of the International Classification of Diseases (ICD-10). PMSI abstracts for all patients discharged between January 2012 and December 2017 were extracted. We built an Adrenalectomy-risk score (ARS) from logistic regression and calculated operative volume and ARS thresholds defining high-volume centers and high-risk patients with the CHAID method. RESULTS: During the 6-year period of the study, 9820 patients (age: 55 ±â€Š14; F/M = 1.1) were operated upon for adrenal disease. The global 90-day mortality rate was 1.5% (n = 147). In multivariate analysis, postoperative mortality was independently associated with age ≥75 years [odds ratio (OR): 5.3; P < 0.001], malignancy (OR: 2.5; P < 0.001), Charlson score ≥2 (OR: 3.6; P < 0.001), open procedure (OR: 3.2; P < 0.001), reoperation (OR: 4.5; P < 0.001), and low hospital caseload (OR: 1.8; P = 0.010). We determined that a caseload of 32 patients/year was the best threshold to define high-volume centers and 20 ARS points the best threshold to define high-risk patients. CONCLUSION: High-risk patients should be referred to high-volume centers for adrenal surgery.

Is Centralization Needed for Patients Undergoing Distal Pancreatectomy?: A Nationwide Study of 3314 Patients.

OBJECTIVE: The centralization of complex surgical procedures is associated with better postoperative outcomes. However, little is known about the impact of hospital volume on the outcome after distal pancreatectomy. METHODS: Using the French national hospital discharge database, we identified all patients having undergone distal pancreatectomy in France between 2012 and 2015. A spline model was applied to determine the caseload cut-off in annual distal pancreatectomy that influenced 90-day postoperative mortality. RESULTS: A total of 3314 patients were identified. Use of a spline model did not reveal a cut-off in the annual distal pancreatectomy caseload. By taking the median number of distal pancreatectomy (n = 5) and the third quartile (n = 15), we stratified centers into low, intermediate, and high hospital volume groups. The overall postoperative mortality rate was 3.0% and did not differ significantly between these groups. In a multivariable analysis, age, Charlson comorbidity score, septic complications, hemorrhage, shock, and reoperation were independently associated with a greater overall risk of death. However, hospital volume had no impact on mortality after distal pancreatectomy (odds ratio, 0.954; 95% confidence interval, 0.552-1.651, P = 0.867). CONCLUSIONS: Hospital volume does not seem to influence mortality after distal pancreatectomy in France, and centralization may not necessarily improve outcomes.

Specificity of Procedure volume and its Association With Postoperative Mortality in Digestive Cancer Surgery: A Nationwide Study of 225,752 Patients.

OBJECTIVES: We aimed to examine whether the improved outcome of a digestive cancer procedure in high-volume hospitals is specific or correlates with that of other digestive cancer procedures, and determine if the discriminant cut-off of hospital volume may influence postoperative mortality (POM) regardless of the procedure. BACKGROUND: Performing complex surgeries in tertiary centers is associated with improved outcome. However, the association between POM and hospital volume of nonspecific procedures is unknown. METHODS: Patients who underwent colectomy, proctectomy, esophagectomy, gastrectomy, pancreatectomy, and hepatectomy for cancer between 2012 and 2017 were identified in the French nationwide database. Chi-square automatic interaction detector was used to identify the cut-off values of the annual caseload affecting the 90-day POM. A common threshold was estimated by minimization of chi-square distance taking into account the specific mortality of each procedure. RESULTS: Overall, 225,752 patients were identified. Hospitals were categorized according to the procedure volume (colectomy: ≥80 cases/yr, proctectomy: ≥35/yr, esophagectomy: ≥41/yr, gastrectomy: ≥16/yr, pancreatectomy: ≥26/yr, and hepatectomy: ≥76/yr). The overall 90-day POM was 5.1% and varied significantly with volume. The benefits of high volume were transferable across procedures. High-volume hospitals for colorectal cancer surgery significantly influenced the risk of death after hepatectomy (P < 0.001) and pancreatectomy (P < 0.001). The common threshold for all procedures that influenced POM was 199 cases/yr (odds ratio 1.29, P < 0.001). CONCLUSION: In digestive cancer surgery, the volume-POM relationship of one procedure was associated with the volume of other procedures. Thus, tertiary hospitals should be defined according to the common threshold of different procedures.

The Impact of Hospital Volume and Charlson Score on Postoperative Mortality of Proctectomy for Rectal Cancer: A Nationwide Study of 45,569 Patients.

OBJECTIVE: To identify the impact of hospital volume according to Charlson Comorbidity Index (ChCI) on postoperative mortality (POM) after rectal cancer surgery. BACKGROUND: A volume-outcome relationship has been established in complex surgical procedures. However, little is known regarding the impact of hospital volume on POM according to patients' comorbidities after rectal cancer surgery. METHODS: All patients undergoing proctectomy for cancer from 2012 to 2016 were identified in the French nationwide database. Patient condition was assessed on the basis of the validated ChCl and was stratified into 3 groups according to the score (0-2, 3, and ≥4). Chi-square automatic interaction detector (CHAID) was used to identify the cut-off values of the annual proctectomy caseload affecting the 90-day POM. The 90-day POM was analyzed according to hospital volume (low: <10, intermediate: 10-40, and high: ≥41 cases/yr) and ChCI. RESULTS: Among 45,569 rectal cancer resections, the 90-day POM was 3.5% and correlated to ChCI (ChCI 0-2: 1.9%, ChCI 3: 4.9%, ChCI ≥4: 5.8%; P < 0.001). There was a linear decrease in POM with increasing hospital volume (low: 5.6%, intermediate: 3.5%, high: 1.9%; P < 0.001). For low-risk patients (ChCl 0-2), 90-day POM was significantly higher in low and intermediate hospital volume compared with high hospital volume centers (3.2% and 1.8% vs 1.1%; P < 0.001). A significant decrease in postoperative hemorrhage complication rates was observed with increasing center volume (low: 13.3%, intermediate: 11.9%, and high: 9.4%; P < 0.001). After multivariable analysis, proctectomy in low [odds ratio (OR) 2.1, 95% confidence interval (CI) 1.71-2.58, P < 0.001] and intermediate (OR 1.45, 95% CI 1.2-1.75, P < 0.001) hospital volume centers were independently associated with higher risk of mortality. CONCLUSION: The POM after proctectomy for rectal cancer is strongly associated with hospital volume independent of patients' comorbidities. To improve postoperative outcomes, rectal surgery should be centralized.

Failure-to-rescue in Patients Undergoing Pancreatectomy: Is Hospital Volume a Standard for Quality Improvement Programs? Nationwide Analysis of 12,333 Patients.

OBJECTIVE: To evaluate the influence of hospital volume on failure-to-rescue (FTR) after pancreatectomy in France. BACKGROUND: There are growing evidences that FTR is an important source of postoperative mortality (POM) after pancreatectomy. However, few studies have analyzed the volume-FTR relationship following pancreatic surgery. METHODS: All patients undergoing pancreatectomy between 2012 and 2015 were included. FTR is defined as the 90-day POM rate among patients with major complications. According to the spline model, the critical cutoff was 20 resections per year and hospitals were divided into low (<10 resections/an), intermediate (11-19 resections/yr), and high volume centers (≥20 resections/yr). RESULTS: Overall, 12,333 patients who underwent pancreatectomy were identified. The POM was 6.9% and decreased significantly with increased hospital volume. The rate of FTR was 14.5% and varied significantly with hospital volume (18.3% in low hospital volume vs 11.9% in high hospital volume, P < 0.001), age (P < 0.001) and ChCl (CCl0-2: 11.5%, ChCl3: 13%, CCl ≥4:18.6%; P < 0.001). FTR for renal failure was the highest of all complications (40.2%), followed by postoperative shock (36.4%) and cardiac complications (35.1%). The FTR was significantly higher in low and intermediate compared with high volume hospitals for shock, digestive, and thromboembolic complications and reoperation. In multivariable analysis, intermediate (OR = 1.265, CI95%[1.103-1.701], P = 0.045) and low volume centers (OR = 1.536, CI95%[1.165-2.025], P = 0.002) were independently associated with increased FTR rates. CONCLUSION: FTR after pancreatectomy is high and directly correlated to hospital volume, highlighting variability in the management of postoperative complications. Measurement of the FTR rate should become a standard for quality improvement programs.

[An overview of the 2001-2002 cancer activity in the 30 French Regional and University Hospitals, based on PMSI data]. / Bilan d'activité cancérologique 2001-2002 des centres hospitaliers régionaux et universitaires de France à partir des données du PMSI.

This study is intended to describe the cancer-related hospitalisations in the thirty French University and Regional Hospitals (CHR&U). The analysis is carried out on the years 2001 and 2002 databases and uses a relevant PMSI (Medicalisation Program Information System, the French DRG) data analysis program, which is an adapted version of the DAC (Cancer Activity Description) analysis program. Cases are selected from cancer-related diagnoses and procedures. The results provided have been classified according to paediatric and adult populations, to the organ anatomical localisations and to the different types of care : one-day hospitalisations or hospitalisations of more than one day, medical or surgical care, cares which include chemotherapy, radiation therapy or palliative procedures. Cancer-related hospitalisations amount to almost 25 % of the total CHR&U hospitalisations and add up to over a million stays per year. One-day hospitalisations amount to 25% of the cancer-related stays and essentially consist in radiation therapy (50% within the adult category) and for chemotherapy (30%). 26% of the hospitalisations of more than one day are surgical. This study is a first descriptive analysis of cancer-related hospital activity in CHR&U. The next stage will see this analysis applied to patients, using the anonymous patient identification number contained in the PMSI coding.

[Indications for pelvic lymphadenectomy in clinically localized prostate cancer]. / Indications de la lymphadénectomie ilio-obturatrice dans le cancer de la prostate cliniquement localisé.

INTRODUCTION: Pelvic lymphadenectomy for localized prostate cancer (stage T1-T2) provides prognostic information. It can be performed by laparoscopy or by open surgery. Systematic lymphadenectomy is controversial and should be performed according to the stage of the tumour and the type of management. Frozen section examination of lymph nodes during total prostatectomy is also controversial due to its low sensitivity (66%). The objective of this article is to define the indications for lymphadenectomy and frozen section examination. METHODS: Systematic review of the literature. RESULTS: Recommendations concerning the indications for bilateral pelvic lymphadenectomy and frozen section examination for stage T1-T2 prostate cancer as a function of the risk of lymph node metastases. A low risk (<5%) of lymph node metastases is defined by an initial PSA < 10 ng/ml, a Gleason score of biopsies < 7 (3 + 4 or < 50% of grade 4) and possibly non-suspicious lymph node imaging. In this case, prior pelvic lymphadenectomy either some time before or immediately before local treatment is optional (Level of Evidence III-2). Due to the morbidity related to lymphadenectomy, the benefit of the procedure is not justified. However, the following situations are distinguished for open or laparoscopic total prostatectomy: --if open total prostatectomy is considered, exploration of the lymph nodes by palpation at the beginning of the operation is recommended. If exploration does not suggest any lymph node invasion, lymphadenectomy is then optional (without frozen section examination). If exploration shows induration or a mass deforming the shape of the lymph nodes, lymphadenectomy is recommended. Frozen section examination is requested only when the surgeon decides not to perform prostatectomy in the case of lymph node invasion. Lymphadenectomy without frozen section examination is optional in the case of laparoscopic total prostatectomy. Macroscopic examination of any lymph node invasion is less accurate via laparoscopy. A high risk (> 5%) of lymph node metastases is defined by a PSA > 10 ng/ml and/or a Gleason score > 7 (4 + 3 or > 50% of grade 4), and/or suspicious lymph node imaging. Pelvic lymphadenectomy is then recommended (Level of Evidence III-2). The following situations can be distinguished according to the type of treatment envisaged (total prostatectomy or external radiotherapy): when the surgeon decides not to perform total prostatectomy in the case of microscopic or macroscopic lymph node invasion (pN1), lymphadenectomy (open or laparoscopic) may be performed either before or at the same time as prostatectomy with frozen section examination. In the case of external radiotherapy, laparoscopic (or open) lymphadenectomy is recommended (without frozen section examination) when it is decided to extend the irradiation field to pelvic lymph nodes in the case of stage pN1 (1st option) or withhold radiotherapy (2nd option). Lymphadenectomy is optional in other cases, as lymphadenectomy induces considerable morbidity and the benefit of systematic pelvic lymph node irradiation has not been demonstrated. It should be stressed that all indications for lymphadenectomy for localized prostate cancer proposed in the literature are based on the results of standard or limited pelvic lymphadenectomy. These indications could be revised if it is confirmed that lymphadenectomy extended to the internal iliac nodes, for patients at high risk of lymph node invasion, is truly informative and contributive to the treatment decision.