The Theory and Practice of Pancreatic Surgery in France.

OBJECTIVE: Measure the caseload of pancreatectomies that influences their short-term outcome, at a national level, and assess the applicability of a centralization policy. BACKGROUND: There is agreement that pancreatectomies should be centralized. However, previous studies have failed to accurately define a "high-volume" center. METHODS: French healthcare databases were screened to identify all adult patients who had elective pancreatectomies between 2007 and 2012. The patients' age, comorbidities, indication, and extent of surgery, and also the hospital administrative-type and location were retrieved. The annual-caseload of pancreatectomy was calculated for each hospital facility. The primary endpoint was 90-day mortality. Spline modeling was used to identify the different annual-caseload that influenced mortality. Logistic regressions were performed to assess if their influence was independent of confounders, and the accuracy of the model calculated. RESULTS: Overall, 22,366 patients underwent a pancreatectomy and the mortality was 8.1%. Two cut-offs were identified (25 and 65 per year): compared with centers performing >65 resections per year, the adjusted OR of mortality was 1.865 (1.529-2.276) in centers performing ≤25 resections per year and 1.234 (1.031-1.478) in those performing 26 to 65 resections per year. The average number of facilities performing ≤25, 26 to 65, and >65 pancreatectomies per year was 456, 20, and 9, respectively. The percentage of patients operated in these facilities was 56.6%, 19.9%, and 23.3%, respectively.For pancreaticoduodenectomies (12,670 patients; mortality 9.2%), there were 2 cut-offs (16 and 40 pancreaticoduodenectomies per year), and both were independent predictors of mortality (adjusted OR of 1.979 and 1.333). For distal pancreatectomies (7085 patients; 6.2% mortality), there were 2 cut-offs (13 and 25 distal pancreatectomies per year), but neither was an independent predictor of outcome (area under the receiver-operating characteristic curve of the model = 0.778). CONCLUSIONS: Centralization of pancreatic surgery is theoretically justified, but currently unrealizable. As the incidence of pancreatic cancer increases, there is an urgent need to improve the training of surgeons and develop both intermediate and high-volume centers.

Impact of emerging hepatitis C virus treatments on future needs for liver transplantation in France: a modelling approach.

BACKGROUND: In light of the impact of emerging hepatitis C virus treatments on morbidity and mortality, we sought to determine whether candidates for liver transplantation for hepatocellular carcinoma and decompensated cirrhosis will decrease sufficiently to match liver grafts for hepatitis C virus-infected patients. AIMS: Using a Markov model, we quantified future liver graft needs for hepatitis C virus-induced diseases and estimated the impact of current and emerging treatments. METHODS: We simulated progression of yearly-hepatitis-C-virus-infected cohorts from the beginning of the epidemic and calculated 2013-2022 candidates for liver transplantation up until 2022 without and with therapies. We compared these estimated numbers to projected trends in liver grafts for hepatitis C virus. RESULTS: Overall, current treatment would avoid transplantation of 4425 (4183-4684) potential candidates during the period 2013-2022. It would enable an 88% and 42% reduction in the gap between liver transplantation activity and candidates for hepatocellular carcinoma and decompensated cirrhosis, respectively. Emerging hepatitis C virus treatments would allow adequacy in transplant activities for hepatocellular carcinoma. However, they would not lead to adequacy in decompensated cirrhosis from 2013 to 2022. Results were robust to sensitivity analysis. CONCLUSION: Our study indicates that patients will benefit from public health policies regarding hepatitis C virus screening and therapeutic access to new emerging treatments.

Pathology report assessment of incidental gallbladder carcinoma diagnosed from cholecystectomy specimens: results of a French multicentre survey.

AIMS: To assess the accuracy of pathology reports on gallbladder specimens from patients operated on for incidental gallbladder carcinoma. METHODS: Demographic data, details on pathological reports including gross and microscopic features section were recorded in 100 selected patients with incidental gallbladder carcinoma diagnosed from 2004 to 2007. RESULTS: Pathology reports had a conventional format in 93% of cases, without any standardization. Turnaround time ranged from 1 to 35 days. Frozen sections were performed in 20% of cases. The reports failed to give information on prognostic histological factors: exact tumour site (missing in 55% of cases), depth of tumour infiltration within the gallbladder wall (missing in 10%), surgical margins (missing in 40% for the cystic duct margin), tumour differentiation (missing in 28%), vascular invasion (missing in 52%) and perineural invasion (missing in 51%). Lymph node status could be assessed in 44% of cases. Distances between the tumour and the cystic duct and circumferential margins were not specified in 68% and 84% of cases. Only 29% of the reports clearly stated the pTNM stage in the conclusion section. The pT stage with margin status and tumour site was only mentioned in 30% of the reports. CONCLUSION: Pathology reports on gallbladder carcinoma from participating centres frequently lacked important information on key prognostic histological factors.

Right hepatectomy with extra-hepatic vascular division prior to transection: intention-to-treat analysis of a standardized policy.

BACKGROUND: Right hepatectomy (RH) is the most common type of major hepatectomy and can be achieved without portal triad clamping (PTC) in non-cirrhotic liver. The present study reviews our standardized policy of performing RH without systematic PTC. METHODS: One hundred and eighty-one consecutive RH were performed in non-cirrhotic patients, with division of the right afferent and efferent blood vessels prior to transection, without systematically using PTC. Prospectively collected data were analysed, focusing on the following endpoints: need for salvage PTC, ischaemic time, blood loss and post-operative outcome. RESULTS: Extra-hepatic division of the right hepatic vessels was feasible in all patients, but was ineffective in 48 patients (26.5%) who required salvage PTC during transection. In those patients, the median ischaemic time was 20 min. The median blood loss was 500 ml (50-3000). Six patients (3.3%) experienced post-operative liver failure. Overall morbidity, severe morbidity and mortality were 42%, 12.1% and 1.6%, respectively, with peri-operative transfusion rate (16.6%) being the only factor associated with morbidity. DISCUSSION: By performing RH with extra-hepatic vascular division prior to transection, PTC can be safely avoided in the majority of patients.

Assessment of pathology reports on hilar cholangiocarcinoma: the results of a nationwide, multicenter survey performed by the AFC-HC-2009 study group.

BACKGROUND & AIMS: To assess the accuracy of pathology reports in patients operated on for hilar cholangiocarcinoma. METHODS: Pathology reports for 263 patients operated on in 22 tertiary hepatobiliary centers were reviewed. The report format, turnaround time, tissue specimens, intraoperative consultations, macroscopic and microscopic descriptions, and conclusions were assessed. RESULTS: Surgeons provided pathologists with pertinent clinical and imaging data in only 14% of cases and gave information on specimen orientation in only 24% of cases. The reports frequently failed to give information on prognostic histological factors: tumor differentiation (missing in 27% of cases), vascular invasion (45%), tumor thickness (99%), and infiltration of the bile duct surgical margins (4%). Distances between the tumor and the vessel margin, liver margin and the periductal soft tissue circumferential margin were not specified in 87%, 79%, and 89% of cases, respectively. Only 21% of the reports gave the pTNM stage in the conclusion section. A lack of information prevented retrospective pTNM staging in 48% of cases. Three percent of the reports had discrepancies in their conclusion section. CONCLUSIONS: Our French, nationwide study revealed that pathology reports on hilar cholangiocarcinoma frequently lack important information on the main prognostic histological factors and pTNM staging. We recommend the use of a standardized pathology report in this context.