Prognosis of poorly cohesive gastric cancer after complete cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy (CYTO-CHIP study).

BACKGROUND: The incidence of gastric poorly cohesive carcinoma (PCC) is increasing. The prognosis for patients with peritoneal metastases remains poor and the role of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is controversial. The aim was to clarify the impact of gastric PCC with peritoneal metastases treated by CRS with or without HIPEC. METHODS: All patients with peritoneal metastases from gastric cancer treated with CRS with or without HIPEC, in 19 French centres, between 1989 and 2014, were identified from institutional databases. Clinicopathological characteristics and outcomes were compared between PCC and non-PCC subtypes, and the possible benefit of HIPEC was assessed. RESULTS: In total, 277 patients were included (188 PCC, 89 non-PCC). HIPEC was performed in 180 of 277 patients (65 per cent), including 124 of 188 with PCC (66 per cent). Median overall survival (OS) was 14.7 (95 per cent c.i. 12.7 to 17.3) months in the PCC group versus 21.2 (14.7 to 36.4) months in the non-PCC group (P < 0.001). In multivariable analyses, PCC (hazard ratio (HR) 1.51, 95 per cent c.i. 1.01 to 2.25; P = 0.044) was associated with poorer OS, as were pN3, Peritoneal Cancer Index (PCI), and resection with a completeness of cytoreduction score of 1, whereas HIPEC was associated with improved OS (HR 0.52; P < 0.001). The benefit of CRS-HIPEC over CRS alone was consistent, irrespective of histology, with a median OS of 16.7 versus 11.3 months (HR 0.60, 0.39 to 0.92; P = 0.018) in the PCC group, and 34.5 versus 14.3 months (HR 0.43, 0.25 to 0.75; P = 0.003) in the non-PCC group. Non-PCC and HIPEC were independently associated with improved recurrence-free survival and fewer peritoneal recurrences. In patients who underwent HIPEC, PCI values of below 7 and less than 13 were predictive of OS in PCC and non-PCC populations respectively. CONCLUSION: In selected patients, CRS-HIPEC offers acceptable outcomes among those with gastric PCC and long survival for patients without PCC.

Development and internal validation of a diagnostic score for gastric linitis plastica.

BACKGROUND: There is no consensual definition for gastric linitis plastica (GLP). We aim to construct a diagnostic score to distinguish this rare tumor from usual gastric adenocarcinomas. METHODS: In this retrospective study, all patients who had gastrectomy for cancer between 2007 and 2017 in French tertiary centers were included. The outcome was a diagnosis of GLP based on pathological review of the surgical specimen. The diagnostic score was created by using variables that were most frequently associated with GLP using penalized logistic regression on multiply imputed datasets. We used discrimination measures to assess the performances of the score. Internal validation was performed using bootstrapping methods to correct for over-optimism. RESULTS: 220 patients including 71 linitis plastica (female 49%, median age 57 years) were analyzed. The six parameters retained in the diagnosis score were the presence of large folds and/or parietal thickening on at least one segment, pangastric infiltration and presence of gastric stenosis on the upper endoscopy, circumferential thickening on at least one segment and thickening of the third hyperechogenic layer on endoscopic ultrasound and the presence of signet ring cells on endoscopic biopsies. The area under the ROC curve (AUC) was 0.967 with a sensitivity of 94% [89.9-97.3] and a specificity of 88.7% [81.7-95.8] for a threshold of 2.75. After internal validation, the corrected AUC was 0.959. CONCLUSION: It is the first study validating a pre-therapeutic diagnostic score (Saint Louis linitis score) with an excellent ability to discriminate GLP from non-GLP adenocarcinomas. An external validation is necessary to confirm our data.

Evaluation of the CT Scan as the First Examination for the Diagnosis and Therapeutic Strategy for Acute Cholecystitis.

BACKGROUND: The CT scan has supplanted the abdominal ultrasound for emergency examinations. A comparison of CT scan and ultrasound performance for the diagnosis and management of acute cholecystitis in acute care was proposed. The hypothesis is that the CT scan may be sufficient for the diagnosis of acute cholecystitis, which would allow faster progress to surgery. METHODS: The retrospective study of consecutive patients operated for acute cholecystitis or gallbladder distension with pre-operative imaging within 48 h in one centre. RESULTS: Between 2015 and 2017, a total of 341 cholecystectomies were performed in our centre. The analysis involved 120 patients. Ultrasound had better sensitivity than the CT scan, respectively, 79.4% [70.5-86.6] and 52.3% [42.5-62.1], but less specificity, with 61.5% [31.6-86.1] and 92.3% [64.0-99.8], respectively. However, there was a significant difference in favour of the CT scan for the diagnosis of complicated cholecystitis (p 0.004). The positive likelihood ratio of complicated cholecystitis is better at CT scan (7.8) [2.7-23.1] than in ultrasound (1.0) [0.1-9.7]. CT scan and ultrasound are equivalent for the diagnosis of acute cholecystitis, but CT scan is more efficient for the diagnosis of complicated cases (Youden index J 0.3 vs 0.001). CONCLUSION: It is possible to place the surgical indication of cholecystectomy on the only data of the CT scan. We propose a decision-making algorithm that uses the CT scan to make the diagnosis and decide on emergency treatment for complicated cases or that allows us to propose a delayed surgery for simple cholecystitis.

Preoperative evaluation of small bowel complications in Crohn's disease: comparison of diffusion-weighted and contrast-enhanced MR imaging.

PURPOSE: To compare the accuracy of MR enterography (MRE) using combined T2-weighted and contrast-enhanced (CE) sequences with that of combined T2- and diffusion-weighted (DW) sequences for the detection of complex enteric Crohn's disease (CD). MATERIALS: Thirty-eight patients who underwent surgery for CD complications and preoperative MRE from 2011 to 2016 were included. MRE examinations were blindly analyzed independently by one junior and one senior abdominal radiologist for the presence of fistula, stenosis and abscesses. During a first reading session, T2-weighted images (WI), steady-state sequences and DW-MRE were reviewed (set 1). During a separate distant session, T2-WI, True-FISP and CE-MRE were reviewed (set 2). Performance of each reader was evaluated by comparison with the standard of reference established using intraoperative and pathological findings. RESULTS: Forty-eight fistulas, 43 stenoses and 11 abscesses were found. For the senior radiologist, sensitivity for the detection of fistula, stenosis and abscess ranged from 80% to 100% for set 1 and 88% to 100% for set 2 and specificity ranged from 56% to 70% for set 1 and 53% to 93% for set 2, with no significant difference between the sets (p = 0.342-0.429). For the junior radiologist, sensitivity ranged from 53% to 63% for set 1 and 64% to 88% for set 2 and specificity ranged from 0% to 25% for set 1 and 17% to 40% for set 2 (p = 0.001 and 0.007, respectively). CONCLUSION: For a senior radiologist, DW-MRE has similar sensitivity as CE-MRE for the detection of CD complications. For a junior radiologist, CE-MRE yields the best results compared with DW-MRE. KEY POINTS: • For experienced readers, DWI has similar diagnostic capability as contrast-enhanced MR imaging for the diagnosis of Crohn's disease complications. • For senior radiologists, gadolinium chelate injection could be waived for the diagnosis of Crohn's disease complications. • The interpretation of DWI for Crohn's disease complications requires some experience.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei of appendicular and extra-appendicular origin.

BACKGROUND: The prognostic value of the primary neoplasm responsible for pseudomyxoma peritonei (PMP) remains poorly studied. The aim of this study was to determine the prognosis for patients with extra-appendicular PMP (EA-PMP) treated optimally with complete cytoreductive surgery (CCRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: All patients treated for PMP with CCRS and HIPEC between 1994 and 2016 were selected retrospectively from a French multicentre database. Patients with EA-PMP had pathologically confirmed non-neoplastic appendices and were matched in a 1 : 4 ratio with patients treated for appendicular PMP (A-PMP), based on a propensity score. RESULTS: Some 726 patients were identified, of which 61 (EA-PMP group) were matched with 244 patients (A-PMP group). The origins of primary tumours in the EA-PMP group included the ovary (45 patients), colon (4), urachus (4), small bowel (1), pancreas (1) and unknown (6). The median peritoneal carcinomatosis index was comparable in EA-PMP and A-PMP groups (15·5 versus 18 respectively; P = 0·315). In-hospital mortality (3 versus 2·9 per cent; P = 1·000) and major morbidity 26 versus 25·0 per cent; P = 0·869) were also similar between the two groups. Median follow-up was 66·9 months. The 5-year overall survival rate was 87·8 (95 per cent c.i. 83·2 to 92·5) per cent in the A-PMP group and 87 (77 to 96) per cent in the EA-PMP group. The 5-year disease-free survival rate was 66·0 (58·7 to 73·4) per cent and 70 (53 to 83) per cent respectively. CONCLUSION: Overall and disease-free survival following treatment with CCRS and HIPEC is similar in patients with pseudomyxoma peritonei of appendicular or extra-appendicular origin.

Impact of obesity after cytoreductive surgery and intraperitoneal hyperthermic chemotherapy for rare peritoneal malignancies: Paradox of obesity or poor prognostic factor?

BACKGROUND: Obesity is a public health concern with an increasing occurrence worldwide. Literature regarding impact of obesity on results after management of peritoneal carcinomatosis is poor. Our aim was to compare postoperative and oncological outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for rare peritoneal malignancies according to the body mass index. METHODS: All the patients managed by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for rare peritoneal malignancies (including mainly pseudomyxoma peritonei and peritoneal mesothelioma), between 1995 and 2020, were retrospectively included from the French national registry of rare peritoneal tumors. RESULTS: 1450 patients were retrospectively included (63.5 % female, mean age 54 ± 13 years). Patients were divided into two groups according to their body mass index: non-obese (n = 1248, 86 %) and obese (n = 202, 14 %). Overall morbidity was significantly lower in non-obese patients in comparison with obese patients (n = 532/1248, 43 % vs n = 106/202, 53 %, p = 0.009). Medical and surgical morbidities were significantly lower in non-obese patients in comparison with obese patients (423/1258, 34 % vs n = 86/202, 43 %, p = 0.02 and n = 321/1248, 26 % vs n = 67/202, 33 %, p = 0.003, respectively). One-, 5- and 10-year overall survivals were similar between non-obese and obese patients (95 %, 82 % and 70 % vs 94 %, 76 % and 63 %; p = 0.1). One-, 5- and 10-year disease free survivals were similar between non-obese and obese patients (84 %, 67 % and 61 % vs 79 %, 62 % and 56 %, p = 0.1). CONCLUSION: Obese patients have to be carefully managed after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for rare peritoneal malignancies. Some perioperative prophylactic treatments could be specifically implemented to reduce thromboembolic events, metabolic and wound complications.

Validation of a live animal model for training in endoscopic hemostasis of upper gastrointestinal bleeding ulcers.

BACKGROUND AND STUDY AIMS: The management of upper gastrointestinal bleeding requires training of the endoscopist. We aimed to validate a live animal model of bleeding ulcers for training in endoscopic hemostasis. MATERIALS AND METHODS: Bleeding ulcers were created by repeated grasp-and-snare gastric mucosectomies in pigs rendered "bleeders" by preadministration of clopidogrel, aspirin, and unfractionated heparin. The feasibility and reproducibility of the model (proportion of bleeding ulcers, number of ulcers per animal, and time needed to produce a bleeding ulcer) were prospectively evaluated in six animals. Ten endoscopic experts assessed the similarity of this pig model to human bleeding ulcers (four-point Likert scale). The training capabilities of the model for hemostatic techniques (needle injection, bipolar electrocoagulation, and hemoclipping) were evaluated in 46 fellows (four-point Likert scale). RESULTS: A total of 53 gastric ulcers were created in 6 animals (8.8 ± 1.5 ulcers/animal). Successful active ulcer bleeding (Forrest Ib) was achieved in 96.2 % of cases. Bleeding was moderate to abundant in 79 % of cases. Ulcerations consistently reached the submucosal layer. The mean (± SD) time taken to create a bleeding ulcer was 3.8 ± 0.6 minutes. Endoscopic experts assessed the realism of the ulcers and bleeding at 3.2 ± 0.7 and 3.6 ± 0.7 respectively on a four-point Likert scale. The training significantly improved the endoscopic skills of the 46 fellows (P < 0.0001) in all hemostatic techniques. CONCLUSIONS: The live porcine model of bleeding ulcers was demonstrated to be realistic, reproducible, feasible, time efficient, and easy to perform. It was favorably assessed as an excellent model for training in endoscopic treatment of bleeding ulcers.

Management of postoperative pancreatic fistula after pancreaticoduodenectomy.

A postoperative pancreatic fistula (POPF) is the main complication after cephalic pancreaticoduodenectomy (CPD). Unlike its prevention, the curative management of POPFs has long been poorly codified. This review seeks best practices for managing POPFs after CPD. The diagnosis of a POPF is based on two signs: (i) an amylase level in drained fluid more than 3 times the upper limit of the blood amylase level; and (ii) an abnormal clinical course. In the standardised definition of the International Study Group of Pancreatic Surgery, a purely biochemical fistula is no longer counted as a POPF and is treated by gradual withdrawal of the drain over at most 3 weeks. POPF risk can be scored using pre- and intraoperative clinical criteria, many of which are related to the quality of the pancreatic parenchyma and are common to several scoring systems. The prognostic value of these scores can be improved as early as Day 1 by amylase assays in blood and drained fluid. Recent literature, including in particular the Dutch randomised trial PORSCH, argues for early systematic detection of a POPF (periodic assays, CT-scan with injection indicated on standardised clinical and biological criteria plus an opinion from a pancreatic surgeon), for rapid minimally invasive treatment of collections (percutaneous drainage, antibiotic therapy indicated on standardised criteria) to forestall severe septic and/or haemorrhagic forms, and for the swift withdrawal of abdominal drains when the risk of a POPF is theoretically low and evolution is favourable. A haemorrhage occurring after Day 1 always requires CT angiography with arterial time and monitoring in intensive care. Minimally invasive treatment of a POPF (radiologically-guided percutaneous drainage or, more rarely, endoscopic drainage, arterial embolisation) should be preferred as first-line treatment. The addition of artificial nutrition (enteral via a nasogastric or nasojejunal tube, or parenteral) is most often useful. If minimally invasive treatment fails, then reintervention is indicated, preserving the remaining pancreas if possible, but the expected mortality is higher.

Social inequalities in health: How do they influence the natural history of colorectal cancer?

As regards colorectal cancer (CRC) in France, social inequalities in health (SIH) exist. Underprivileged patients are characterized by reduced incidence of CRC and, conversely, by excess mortality. The explanatory mechanisms of the SIHs influencing survival are complex, multidimensional and variable according to healthcare system. Among the most deprived compared to the least deprived patients, SIHs are reflected by lower participation in screening campaigns, and CRC diagnosis is more frequently given at a later stage in an emergency context. During treatment, disadvantaged patients are more at risk of having to undergo open surgery and of enduring severe postoperative complications and belated chemotherapy (when recommended). Study of SIHs poses unusual challenges, as it is necessary not only to pinpoint social deprivation, but also to locate the different treatment facilities existing in a given territorial expanse. In the absence of individualized socioeconomic information, research in France on the social determinants of health is based on duly constituted cancer registries, in which an ecological index of social deprivation, the European Deprivation Index (EDI), provides an aggregate measure of the socioeconomic environment of a given individual in a given geographical setting at a given point in time. All in all, studies on SIHs are justified as means of identification and comprehension of the mechanisms underlying social deprivation, the objective being to more precisely orient programs and practices aimed at combating SIH.

PIPAC nebulizer: How to test the new devices in the market, expert recommendations.

Pressurized intraperitoneal aerosol chemotherapy, named PIPAC, is now used in many centers around the world and as an intraperitoneal drug delivery system for treatment of peritoneal carcinomatosis. Recently, many of us have encountered problems during PIPAC procedures due to changes in material and production features of the original PIPAC nebulizer. Concomitantly, new PIPAC nebulizers proposed by other manufacturers are being launched on the market; which claim that they are the same as the original device in delivering PIPAC. However, these new devices are all different in terms of materials, technical characteristics and costs. We have considered that, to maintain the acquired results of PIPAC, we must ensure that the new systems are equivalent. The characteristics deemed essential by the expert group are as follows: 1: The nebulizer must be able to create droplets through an injector pressure between 10 and 20 bars, 2: The mean droplet size must be 3 micrometers, with 95% of the droplets between 0 and 10 micrometers, 3: The diffusion angle must be 70 degrees, which is the minimum.

Accuracy of imaging for predicting operative approach in Crohn's disease.

BACKGROUND: The aim of this study was to assess the accuracy of preoperative imaging in detecting the extent of disease and predicting the operative approach in patients with Crohn's disease. METHODS: Patients with Crohn's disease who were scheduled to undergo operation were evaluated before operation using computed tomography enteroclysis (CTE) and magnetic resonance enterography (MRE). Preoperative imaging findings were correlated with intraoperative and pathological findings to estimate the capabilities of preoperative imaging in detecting lesions due to Crohn's disease. The operative approach determined before surgery was compared with the procedure actually performed, which was based on intraoperative findings. RESULTS: Fifty-two patients with Crohn's disease were studied; 26 were evaluated before surgery with CTE and 26 with MRE. Eighty-nine lesions due to Crohn's disease were confirmed surgically (60 small bowel stenoses, 21 fistulas and 8 abscesses). CTE confirmed the presence of 38 of 41 lesions (sensitivity 93 per cent) and MRE 48 of 48 lesions (sensitivity 100 per cent); a correct estimation of the disease with an exact prediction of the operative approach was obtained in 49 (94 per cent) of 52 patients. Discrepant findings between preoperative imaging and operative findings were observed in three patients (6 per cent), who had CTE. CONCLUSION: Preoperative imaging using CTE or MRE is highly accurate for assessing Crohn's disease lesions before operation, allowing correct prediction of the operative approach.

Flexible versus rigid single-port peritoneoscopy: a randomized controlled trial in a live porcine model followed by initial experience in human cadavers.

INTRODUCTION: We compared single incision laparoscopic surgery with flexible endoscope ("flexible SILS") and with rigid optic ("rigid SILS") for access to 11 elective sites of peritoneal carcinomatosis. MATERIALS AND METHODS: Back-to-back flexible and rigid SILS peritoneoscopy were performed in ten live pigs. SILS peritoneoscopy was performed using a flexible endoscope or a rigid optic, in random order, together with two rigid 5-mm laparoscopic forceps. Primary endpoint was access success rate to 11 elective sites of peritoneal carcinomatosis. Findings for the most favorable option were then assessed in four human cadavers. RESULTS: In the porcine model, the overall rate of access to targets was 98% with flexible SILS and 87% with rigid SILS (p < 0.001). Both flexible and rigid SILS allowed a 100% access rate to diaphragmatic domes, paracolic gutters, splenic and hepatic hilum, pelvic floor, and trigonal bladder. The rates of access to other sites by flexible versus rigid SILS, respectively, were: root of the mesentery (90 vs. 50%), origin of the inferior mesenteric vein (90 vs. 50%), inferior vena cava (100 vs. 90%), and cul-de-sac of Douglas (100 vs. 50%). No complications were observed. Procedures were performed in mean time of 26 and 24 min, respectively. These findings were confirmed for flexible SILS in four human cadavers. CONCLUSIONS: Flexible SILS is superior to rigid SILS to evaluate the peritoneal cavity in a timely manner. This suggests a need for flexible instrumentation or other technical solutions to perform thorough minimally invasive surgical evaluation of peritoneal carcinomatosis.

Prevention of radiation enteritis by interposition of an intra-abdominal spacer before irradiation of an appendiceal tumour abscess drainage route.

The initial presentation of a mucinous adenocarcinoma of the appendix can be a peri-appendicular abscess. The abdominal wall muscles can be invaded during radiological or surgical drainage. The management of such a tumour is complex. The resection of a drainage route can be uncertain and R1. In this case, further treatment with adjuvant radiotherapy may be necessary. One possible deleterious side effect of radiotherapy on the abdominal wall is radiation injury to the bowel. As a preventive measure, a spacer (here a breast prosthesis) can be interposed.

Peritoneal recurrence of colorectal cancer with microsatellite instability: Is immunotherapy alone more effective than surgery?

A 67-year-old man was treated with systemic chemotherapy and cytoreductive surgery for microsatellite instable (MSI), deficient mismatch repair (dMMR) right colonic cancer with peritoneal metastases. Disease was controlled only when anti-PD1 and anti-CTLA4 immune checkpoint inhibitors were introduced. The patient is in complete remission after five years of follow-up. First-line immunotherapy could have a central role in the management of patients with peritoneal recurrence from MSI/dMMR colorectal cancer even though amenable to surgical treatment.

Social deprivation aggravates post-operative morbidity in carcinologic colorectal surgery: Results of the COINCIDE multicenter study.

AIM OF THE STUDY: Evaluate the impact of social deprivation on morbidity and mortality in surgery for colorectal cancer. METHODS: The COINCIDE prospective cohort included nearly 2,000 consecutive patients operated on for colorectal cancer at the Assistance Publique-Hospitals of Paris (AP-HP) from 2008 to 2010. The data on these patients were crossed with the PMSI administrative database. The European Social Deprivation Index (EDI) was calculated for each patient and classified into five quintiles (quintiles 4 and 5 being the most disadvantaged patients). Thirty-day post-operative morbidity was determined according to the Dindo-Clavien classification, with a Had®Hoc re-analysis of each file. Statistical analysis was performed using the proprietary Q-finder® algorithm. RESULTS: One thousand two hundred and fifty nine curative colorectal resections were analyzed. Mortality was 2.7% and severe morbidity (Dindo-Clavien≥3) occurred in 16.4%. Mortality was not statistically significantly increased among the most disadvantaged who made up almost two thirds of the population (64.2%). Patients in quintiles 4 and 5 had a statistically significant increase in severe morbidity. The relative risk remained 1.5 even after adjustment for the known risk factors found in the analysis: age>70 years, ASA score, urgency, and laparotomy. CONCLUSIONS: The EDI represents an independent risk factor for severe morbidity after carcinologic colorectal resection. This study suggests that the determinants of health are multidimensional and do not depend solely on the quality and performance of the care system. The inclusion of this index in our surgical databases is therefore necessary, as is its use in health policy for the distribution of resources.

Lymph road mapping obtained via blue sentinel node detection to avoid middle colic artery resection for highly selected colon cancer cases: proof of a concept?

BACKGROUND: In theory, perioperative detection of lymph nodes with the injection of isosulfan blue dye should provide lymph road mapping (LRM) able to direct the resection. However, there is no supporting evidence for this theory in cases of colon cancer. We reanalysed all operative reports using the sentinel lymph node technique with blue dye injection. MATERIALS AND METHODS: The retrospective study included 140 patients who underwent the sentinel lymph node (SLN) procedure between February 2001 and November 2007, including 70 cases in which the in vivo technique was used. In 8 cases (11%), LRM was used by the surgeon to determine the extent of resection. RESULTS: In 5 cases, including limited or extended resection, the final pathological stage was II at the end of the follow-up period, and the patients had no recurrent disease. However, findings for 3 cases of stage III cancer were more relevant to the aims of this study. In these 3 patients, one with cancer (T3N1(3/22)) located at the hepatic flexure, and 2 with cancers (T3N2(7/41) and T2N2 (4/15)) at the splenic flexure, the middle colic artery was conserved as a result of LRM information. Of these 3 patients, 1 was alive without disease at 6-year follow-up and 2 at 5-year follow-up. CONCLUSION: LRM obtained via blue sentinel node detection makes it possible to avoid middle colic artery resection for selected colon cancer cases. LRM seems particularly suitable in cases of colonic flexure location or prior colon surgery.

Bowel obstruction due to a right paraduodenal hernia with midgut malrotation.

Right paraduodenal internal hernia, which has an embryonic origin, can be a rare cause of bowel obstruction, generally in young adults. We report the case of a young man who sought emergency care for acute abdominal pain with obstruction.

Restricted access to innovative surgical technique related to a specific training, is it ethical? Example of the PIPAC procedure. A systematic review and an experts survey.

OBJECTIVE: Using the example of Pressurized Intra Peritoneal Aerosol Chemotherapy (PIPAC), we analyse the development model of this procedure and provide an ethical analysis of the involvement of the industry in a new development. SUMMARY BACKGROUND DATA: In the case of breakthrough innovation, medical training is essential for safe use of the new procedure. In some cases, pharmaceutical companies decide to organise this training. But when it becomes the only training opportunity to use the device, scientists and clinicians could be exposed to a conflict of interest? METHODS: We performed a literature review of PIPAC publications using the STROBE criteria. Then, we conducted interviews with an expert panel to analyse the ethical impact of involvement of the industry in the development of the PIPAC procedure. RESULTS: The number of publications has increased every year since the first publication in Germany, where the technology was developed in 2013. The scientific production was of good quality, with a mean STROBE score of 18.2 ± 2.4 out of 22 points. Ten of the 33 included studies declared a conflict of interest. From the interviews, the main axe concerning the implication of the industry was the training model. The company had decided that only trained and approval surgeon could perform the PIPAC procedure. All four interviewed practitioners agreed that it was initially a good way to implement the procedure safely, but later they felt uncomfortable about the control and validation by the industry. CONCLUSION: Based on the growing number of published papers from a growing number of international centres, the controlled training model is not limiting. However, the different levels of conflict of interest complicate transparency, and we postulated that this development model is limited to the beginning of the procedure diffusion. CLINICALTRIAL. GOV REGISTRATION: NCT04341337.

Strategy for the practice of digestive and oncological surgery during the Covid-19 epidemic.

The Covid-19 pandemic is changing the organization of healthcare and has a direct impact on digestive surgery. Healthcare priorities and circuits are being modified. Emergency surgery is still a priority. Functional surgery is to be deferred. Laparoscopic surgery must follow strict rules so as not to expose healthcare professionals (HCPs) to added risk. The question looms large in cancer surgery-go ahead or defer? There is probably an added risk due to the pandemic that must be balanced against the risk incurred by deferring surgery. For each type of cancer-colon, pancreas, oesogastric, hepatocellular carcinoma-morbidity and mortality rates are stated and compared with the oncological risk incurred by deferring surgery and/or the tumour doubling time. Strategies can be proposed based on this comparison. For colonic cancers T1-2, N0, it is advisable to defer surgery. For advanced colonic lesions, it seems judicious to undertake neoadjuvant chemotherapy and then wait. For rectal cancers T3-4 and/or N+, chemoradiotherapy is indicated, short radiotherapy must be discussed (followed by a waiting period) to reduce time of exposure in the hospital and to prevent infections. Most complex surgery with high morbidity and mortality-oesogastric, hepatic or pancreatic-is most often best deferred.