Recommendations for nutritional care after bariatric surgery: Recommendations for best practice and SOFFCO-MM/AFERO/SFNCM/expert consensus.

Nutritional care after bariatric surgery is an issue of major importance, especially insofar as risk of deficiency has been extensively described in the literature. Subsequent to the deliberations carried out by a multidisciplinary working group, we are proposing a series of recommendations elaborated using the Delphi-HAS (official French health authority) method, which facilitates the drawing up of best practice and consensus recommendations based on the data of the literature and on expert opinion. The recommendations in this paper pertain to dietary management and physical activity, multivitamin and trace element supplementation and the prevention and treatment of specific deficiencies in vitamins B1, B9, B12, D and calcium, iron, zinc, vitamins A, E and K, dumping syndrome and reactive hypoglycemia.

Long-term follow-up after bariatric surgery in a national cohort.

BACKGROUND: Lifelong medical follow-up is mandatory after bariatric surgery. The aim of this study was to assess the 5-year follow-up after bariatric surgery in a nationwide cohort of patients. METHODS: All adult obese patients who had undergone primary bariatric surgery in 2009 in France were included. Data were extracted from the French national health insurance database. Medical follow-up (medical visits, micronutrient supplementation and blood tests) during the first 5 years after bariatric surgery was assessed, and compared with national and international guidelines. RESULTS: Some 16 620 patients were included in the study. The percentage of patients with at least one reimbursement for micronutrient supplements decreased between the first and fifth years for iron (from 27.7 to 24.5 per cent; P < 0.001) and calcium (from 14·4 to 7·7 per cent; P < 0·001), but increased for vitamin D (from 33·1 to 34·7 per cent; P < 0·001). The percentage of patients with one or more visits to a surgeon decreased between the first and fifth years, from 87·1 to 29·6 per cent (P < 0·001); similar decreases were observed for visits to a nutritionist/endocrinologist (from 22·8 to 12·4 per cent; P < 0·001) or general practitioner (from 92·6 to 83·4 per cent; P < 0·001). The mean number of visits to a general practitioner was 7·0 and 6·1 in the first and the fifth years respectively. In multivariable analyses, male sex, younger age, absence of type 2 diabetes and poor 1-year follow-up were predictors of poor 5-year follow-up. CONCLUSION: Despite clear national and international guidelines, long-term follow-up after bariatric surgery is poor, especially for young men with poor early follow-up.

Abdominal desmoplastic small round cell tumor without extraperitoneal metastases: Is there a benefit for HIPEC after macroscopically complete cytoreductive surgery?

BACKGROUND: Desmoplastic Small Round Cell Tumor (DSRCT) is a rare disease affecting predominantly children and young adults and for which the benefit of hyperthermic intraperitoneal chemotherapy (HIPEC) after complete cytoreductive surgery (CCRS) remains unknown. METHODS: To identify patients with DSRCT without extraperitoneal metastases (EPM) who underwent CCRS between 1991 and 2015, a retrospective nation-wide survey was conducted by crossing the prospective and retrospective databases of the French Network for Rare Peritoneal Malignancies, French Reference Network in Sarcoma Pathology, French Sarcoma Clinical Network and French Pediatric Cancer Society. RESULTS: Among the 107 patients with DSRCT, 48 had no EPM and underwent CCRS. The median peritoneal cancer index (PCI) was 9 (range: 2-27). Among these 48 patients, 38 (79%) had pre- and/or postoperative chemotherapy and 23 (48%) postoperative whole abdominopelvic radiotherapy (WAP-RT). Intraperitoneal chemotherapy was administered to 11 patients (23%): two received early postoperative intraperitoneal chemotherapy (EPIC) and nine HIPEC. After a median follow-up of 30 months, the median overall survival (OS) of the entire cohort was 42 months. The 2-y and 5-y OS were 72% and 19%. The 2-y and 5-y disease-free survival (DFS) were 30% and 12%. WAP-RT was the only variable associated with longer peritoneal recurrence-free survival and DFS after CCRS. The influence of HIPEC/EPIC on OS and DFS was not statistically conclusive. CONCLUSION: The benefit of HIPEC is still unknown and should be evaluated in a prospective trial. The value of postoperative WAP-RT seems to be confirmed.

Hyperthermic intraperitoneal chemotherapy with cisplatin: Amifostine prevents acute severe renal impairment.

UNLABELLED: Surgical cytoreduction combined with intraperitoneal chemo-hyperthermia (HIPEC) has shown to provide survival benefits in the management of some peritoneal carcinomatosis. The cisplatin (CP) used in HIPEC carries a risk of renal impairment (RI). This risk could be reduced by administration of amifostine (A). The aim of our study was to assess the utility of A in preventing RI during IPCH with CP. PATIENTS AND METHODS: Retrospective study including patients who underwent HIPEC between January 2007 and June 2013. The HIPEC involved administration of CP and mitomycin C, between 41 and 43 °C. The peri-anaesthetic management was consistent to use A after 2010. Renal function was assessed from the measured creatinine clearance (CreatCl) and the change between D0 and D4 was compared between patients who received A (group A+) and those who did not (group A-). Severe RI was defined as the development of a CreatCl of <30 ml/min. The statistical analysis used a Student t-test and Fischer's exact test. A p-value of <0.05 was deemed to be statistically significant. RESULTS: Over the studied period, seventy five patients underwent HIPEC and the findings from fifty two patients were analysed: thirty one in group A+ and twenty one in group A-. The change in mean CreatCl from D0 to D4 did not differ between the two groups although between D1 and D4 a significantly higher percentage of severe RI was seen in group A-. CONCLUSIONS: This study has shown A to offer benefit in terms of reducing severe RI when CP is used in HIPEC. These results, however, will need to be confirmed in prospective series on larger numbers of patients.

Professional risks when carrying out cytoreductive surgery for peritoneal malignancy with hyperthermic intraperitoneal chemotherapy (HIPEC): A French multicentric survey.

BACKGROUND: Over the last two decades, many surgical teams have developed programs to treat peritoneal carcinomatosis with extensive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Currently, there are no specific recommendations for HIPEC procedures concerning environmental contamination risk management, personal protective equipment (PPE), or occupational health supervision. METHODS: A survey of the institutional practices among all French teams currently performing HIPEC procedures was carried out via the French network for the treatment of rare peritoneal malignancies (RENAPE). RESULTS: Thirty three surgical teams responded, 14 (42.4%) which reported more than 10 years of HIPEC experience. Some practices were widespread, such as using HIPEC machine approved by the European Community (100%), individualized or centralized smoke evacuation (81.8%), "open" abdominal coverage during perfusion (75.8%), and maintaining the same surgeon throughout the procedure (69.7%). Others were more heterogeneous, including laminar flow air circulation (54.5%) and the provision of safety protocols in the event of perfusate spills (51.5%). The use of specialized personal protective equipment is ubiquitous (93.9%) but widely variable between programs. CONCLUSION: Protocols regarding cytoreductive surgery/HIPEC and the associated professional risks in France lack standardization and should be established.

Peritoneal carcinomatosis treated with cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for advanced ovarian carcinoma: a French multicentre retrospective cohort study of 566 patients.

BACKGROUND: Despite a high response rate to front-line therapy, prognosis of epithelial ovarian carcinoma (EOC) remains poor. Approaches that combine Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) have been developed recently. The purpose of this study was to assess early and long-term survival in patients treated with this strategy. PATIENTS AND METHODS: A retrospective cohort multicentric study from French centres was performed. All consecutive patients with advanced and recurrent EOC treated with CRS and HIPEC were included. RESULTS: The study included 566 patients from 13 centres who underwent 607 procedures between 1991 and 2010. There were 92 patients with advanced EOC (first-line treatment), and 474 patients with recurrent EOC. A complete cytoreductive surgery was performed in 74.9% of patients. Mortality and grades 3 to 4 morbidity rates were 0.8% and 31.3%, respectively. The median overall survivals were 35.4 months and 45.7 months for advanced and recurrent EOC, respectively. There was no significant difference in overall survival between patients with chemosensitive and with chemoresistant recurrence. Peritoneal Cancer Index (PCI) that evaluated disease extent was the strongest independent prognostic factor for overall and disease-free survival in all groups. CONCLUSION: For advanced and recurrent EOC, curative therapeutic approach combining optimal CRS and HIPEC should be considered as it may achieve long-term survival in patients with a severe prognosis disease, even in patients with chemoresistant disease. PCI should be used for patient's selection.

Advanced gastric cancer with or without peritoneal carcinomatosis treated with hyperthermic intraperitoneal chemotherapy: a single western center experience.

INTRODUCTION: The aim of this article was to evaluate the role of hyperthermic intraperitoneal chemotherapy (HIPEC), associated or not to cytoreductive surgery (CS) in the treatment of different stages of advanced gastric cancer (AGC). PATIENTS AND METHODS: Thirty seven patients with AGC who underwent 43 HIPEC from June 1992 to February 2007 were included. HIPEC used Mitomycin-C and Cisplatin for 60-90 min at 41-43 degrees C intra-abdominal temperature. The main endpoints were long-term survivals, morbidity and mortality rates. RESULTS: Eleven patients had no demonstrable sign of PC and constituted the Prophylactic-group, while 26 patients had macroscopic PC (PC-group). Five patients were Gilly 1 or 2 (nodules <0.5 cm) and 21 Gilly 3 or 4 (nodules >or=0.5 cm). In the PC-group a complete curative CS was achieved before HIPEC in 8 (PC-curative subgroup) and a palliative HIPEC in 18 patients (PC-palliative subgroup). The overall 30-days mortality was 5% (2 patients). Two patients in the Prophylactic group died within 6 months after hospital discharge (overall mortality 11%). The estimated risk of death per procedure was 9%. Ten patients (27%) presented one or more complications. The median survival was 23.4 months in the Prophylactic group, and 6.6 months in the PC-group (p<0.05). The median survival in the PC-curative subgroup was 15 vs 3.9 months in the PC-palliative subgroup (p=0.007). The median survival according to Gilly classification was significantly different (Gilly 1&2 vs Gilly 3&4, 15 vs 4 months respectively, p=0.014). The global recurrence rates between the Prophylactic group and the PC-curative subgroup at 2years were 36% vs 50% respectively. The median delay to recurrence was 18.5 vs 9.7 months respectively. CONCLUSION: HIPEC might be useful to improve the survival in selected patients with ACG only when a complete cytoreduction can be achieved. Despite encouraging data, prospective studies, based on larger cohorts of patients are required to assess the role of this procedure as a prophylactic treatment in patients with AGC.

Laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of malignant ascites secondary to unresectable peritoneal carcinomatosis from advanced gastric cancer.

AIMS: To review our experience of laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of malignant ascites from advanced gastric cancer in order to discuss benefits, problems and possible indications. METHODS: From June 2000 to May 2003 laparoscopic approach was used to perform HIPEC on five patients affected by malignant ascites secondary to unresectable peritoneal carcinomatosis of gastric origin, in order to associate the benefits of a definitive palliation of ascites with a minimal invasiveness. All patients had ascites related symptoms requiring iterative paracenteses. Intraperitoneal perfusion of mitomycin-C and cisplatin was delivered for 60-90min with an inflow temperature of 45 degrees C. RESULTS: Complete clinical regression of ascites and related symptoms was achieved in all the five patients treated. Intraoperative course was uneventful in all cases. Mean operative time was 181min. No postoperative deaths, related to the procedure, occurred. Only a case of delayed gastric empting was recorded as a minor postoperative complication. CONCLUSIONS: Laparoscopic HIPEC appears to be a safe and effective procedure to treat debilitating malignant ascites from unresectable peritoneal carcinomatosis.

Harmonic scalpel in laparoscopic colorectal surgery.

PURPOSE: With advances in laparoscopy, various hemostatic procedures have been advocated with variable results. Using currently available tools, some steps in laparoscopic colorectal surgery still represent technical challenges. Our aim was to investigate the feasibility and reliability of the Harmonic Scalpel in laparoscopic colorectal surgery. METHODS: In this nonrandomized prospective study, 34 consecutive patients (15 males; mean age, 46 (range, 24-80) years) underwent laparoscopic colorectal surgery for benign disease (27 patients) and colorectal cancer (7 patients). Dissection, hemostasis, coagulation, and division of several types of vascular pedicles were performed exclusively with the Harmonic Scalpel. The 10-mm-blade Harmonic Scalpel device was used at full power mode for all purposes through a 10-mm port. Coagulation of vascular pedicles was always achieved with the blades in the flat position. The large pedicles (inferior mesenteric, right and left colic, and ileocolic) were coagulated for 20 seconds in several locations along the length (1 cm) before final division. Smaller vascular pedicles were coagulated for ten seconds before division. When the vein and the artery of major pedicles were divided at their origin, either for malignancy or for technical reasons, they were dissected and coagulated separately. For more limited resection of the mesentery, as in the case of benign disease, vascular pedicles were coagulated together as a single bundle. Operative time, minor or major intraoperative or postoperative hemorrhage, need for conversion to laparotomy, bowel injury, and trocar complications were recorded. All anastomoses were checked on Day 8 by a diatrizoate sodium enema. RESULTS: There was no mortality. Mean operative time was 276 (range, 200-520) minutes. Neither minor nor uncontrollable hemorrhage occurred; no conversion to laparotomy and no vascular or bowel injury were recorded. There was one port-site hematoma. Neither hemoperitoneum, intraperitoneal hematoma, fistula, nor intra-abdominal abscess was observed. CONCLUSION: Coagulation and division of minor as well as major vascular pedicles in laparoscopic colorectal surgery with the Harmonic Scalpel" are technically easy, feasible, and reliable.

[Radiotherapy and chemotherapy in the treatment of cancer of the rectum]. / Radiothérapie et chimiothérapie dans le traitement du cancer du rectum.

The North American consensus conference held in 1990 concluded that the best currently available adjuvant treatment for cancer of the rectum (T3, N1 to N3) was postoperative combination radiotherapy and chemotherapy. In 1994, the consensus conference held in Paris concluded that the benefit observed after preoperative irradiation warranted assessment of the effect of preoperative radiochemotherapy. To decide between these two consensus conclusions, it would be most logical to compare preoperative radiotherapy with postoperative radiochemotherapy in a group of patients with similar echo-endoscopic or imaging findings.

Senna vs polyethylene glycol for mechanical preparation the evening before elective colonic or rectal resection: a multicenter controlled trial. French Association for Surgical Research.

HYPOTHESIS: Senna is more efficient than polyethylene glycol as mechanical preparation before elective colorectal surgery. DESIGN: Prospective, randomized, single-blind study. SETTING: Multicenter study (18 centers). PATIENTS: Five hundred twenty-three consecutive patients with colonic or rectal carcinoma or sigmoid diverticular disease, undergoing elective colonic or rectal resection followed by immediate anastomosis. INTERVENTION: Two hundred sixty-two patients were randomly allotted to receive senna (1 package diluted in a glass of water) and 261 to receive polyethylene glycol (2 packages diluted in 2-3 L of water), administered the evening before surgery. All patients received 5% povidone iodine antiseptic enemas (2 L) the evening and the morning before surgery. Ceftriaxone sodium and metronidazole were given intravenously at anesthetic induction. MAIN OUTCOME MEASURES: Degree of colonic and rectal cleanliness. RESULTS: Colonic cleanliness was better (P=.006), fecal matter in the colonic lumen was less fluid (P=.001), and the risk for moderate or large intraoperative fecal soiling was lower (P=.11) with senna. Overall, clinical tolerance did not differ significantly between groups, but 20 patients receiving polyethylene glycol (vs 16 with senna) had to interrupt their preparation, and 15 patients (vs 8 with senna) complained of abdominal distension. Senna, however, was better tolerated (P = .03) in the presence of stenosis. There was no statistically significant difference found in the number of patients with postoperative infective complications (14.7% vs 17.7%) or anastomotic leakage (5.3% vs 5.7%) with senna and polyethylene glycol, respectively. CONCLUSION: Mechanical preparation before colonic or rectal resection with senna is better and easier than with polyethylene glycol and should be proposed in patients undergoing colonic or rectal resection, especially patients with stenosis.

[Treatment of gastric cancer]. / Le traitement du cancer gastrique.

Gastric cancer (GC) still remains a major cancer problem in the world. Its prognosis is poor with an overall 5-year survival rate less than 20%. Surgical resection is still the only curative treatment of GC. Curative resection depends on tumoral location and extension, particularly lymph node involvement. Proximal GC (fundus, body) are treated by total gastrectomy (TG). For distal GC (antrum, pylorus), the TG is no more the recommended treatment and distal sub-total gastrectomy can safely be performed when carcinologic rules are respected: 5-6 cm free margin for the remnant stomach and at least 2 cm resection of the proximal duodenum. Cardia cancers, upon to their tumoral extension toward the esophagus, can require either TG or proximal esophagogastrectomy by combined thoracic and abdominal approach. As demonstrated in the last controlled studies, D2 extensive lymphadenectomy, in spite of its contribution to a better prognostic staging, does not improve long term survival after curative surgery. TG extended to the spleen or to the pancreas should not be performed in curative surgery because of a high rate of postoperative complications. Limited gastric resections for superficial GC have to be evaluated in Western countries. Palliative exploratory laparotomies should be avoided by better preoperative explorations. Laparoscopic staging in GC could be indicated when palliative resection or bypass are possible. The results of adjuvant chemotherapy is still disappointing and new protocols have to be evaluated. Intraperitoneal chemotherapy with or without hyperthermia represents a serious hope in the treatment of GC, but its significative action on the survival is not well demonstrated, while its morbidity and mortality rate is high.