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.

[Recovery of maxillary tooth sensibility after Le Fort I osteotomy]. / Récupération de la sensibilité dentaire maxillaire après ostéotomie de Le Fort I.

INTRODUCTION: Upper alveolar nerves, when injured during Le Fort I osteotomies, alter maxillary tooth sensitivity. We had for aim to analyze post-operative maxillary tooth sensitivity recovery. MATERIAL AND METHODS: We conducted a prospective study in a series of patients having undergone Le Fort I osteotomy, with, or without mandibular osteotomy or intermaxillary disjunction (IMD). The direction and range of displacement of the maxillary bone were recorded. One tooth in each alveolar sector (incisivocanine, premolar, molar) was tested with an electric stimulator for each patient. The tests were performed before (D-1), and after surgery (D2 or day+2, D+15, M2 (or month +2), M3, and M6). RESULTS: Twenty-two patients were included. Among the tested teeth, 91.9 % were sensitive at D-1. At D2, only 12.7 % of teeth were sensitive. At D15, M2, M3, and M6, the sensitivity was respectively 33.3 %, 43.1 %, 50 %, and 61.8 %. The recovery of sensitivity was faster in young patients (under 35 years of age) and for upper middle and superior alveolar nerves. There was no difference regarding the direction of maxillary movement. DISCUSSION: Among the teeth that were sensitive before surgery, 87.3 % had not regained sensitivity at D2. The recovery of sensitivity increased at D15. A great displacement of the maxillary bone was an aggravating factor for loss of tooth sensitivity.

[Neurotrophic ulceration following thermocoagulation of the Gasserian ganglion]. / Ulcération neurotrophique après thermocoagulation du ganglion de Gasser.

INTRODUCTION: Neurotrophic ulceration (NTU) in the trigeminal nerve sensitive area is rare. It may be caused by a lesion anywhere on the trigeminal nerve's trajectory. The diagnosis is usually clinical, but other diagnoses, particularly neoplastic, must be ruled out first. The physiopathology and treatment of NTU remain controversial. We report a severe case of NTU and describe the main features of this poorly documented disease. OBSERVATION: A 67-year-old female patient consulted in the dermatology department for a progressive ulceration of the nose ala and the right upper lip, having developed over the two previous years. She had undergone two thermocoagulations of the right Gasserian ganglion for facial neuralgia 3 years before. The diagnosis of NTU, initially ruled out because of biopsies suggesting verrucous carcinoma, was finally retained because of the clinical presentation and anamnesis. Treatment consisted in surgical excision and primary reconstruction using a forehead flap. The diagnosis was confirmed after histopathological examination of the surgical specimen. A recurrence was noted 2 years postoperatively, then the patient was lost to follow-up. DISCUSSION: The physiopathology of NTUs is badly documented. The cutaneous ulcerations look like facial neoplasms but the clinical findings (unilateral and paranasal location; lesion of the trigeminal nerve; local trauma; psychological instability) suggest neurotrophic ulceration. The histopathological examination, sometimes difficult, reveals non-specific chronic inflammatory ulceration. There is no consensus on treatment. The psychological profile may be a risk factor for recurrences and must be taken into account.

[Bilateral post-traumatic adrenal hemorrhage. Report of a case with acute adrenal insufficiency]. / Hémorragie surrénalienne bilatérale post-traumatique. A propos d'un cas avec insuffisance surrénale aiguë.

Bilateral adrenal haemorrhage of traumatic origin is rarely observed or possibly missed in severely multi-traumatised patients. It can lead to a potentially fatal adrenal shock. Its emergency diagnosis is made by imaging techniques, usually by CT-scan. Early substitution therapy has to be done. This complication emphasizes the importance of an immediate abdominal morphological exploration in multi-traumatized patients when this is feasible.

[Results of laparoscopic hernioplasty. A study of 401 cases in 318 patients]. / Résultats des hernioplasties coelioscopiques. Etude de 401 cas chez 318 patients.

STUDY AIM: The aim of this retrospective study was to report a series of laparoscopic hernioplasty performed in two surgical centers, and to evaluate the results with a mean follow-up of 31 months. PATIENTS AND METHODS: From January 1992 to January 1997, 318 patients with 401 inguinal hernias were operated on through laparoscopy by six senior surgeons and six junior surgeons. There were 302 men and 16 women (mean age: 53 years). The operation was performed through an extra-peritoneal approach (TEP) in 298 hernias, a trans-abdomino-preperitoneal approach (TAPP) in 62 hernias, and an intra-abdominal approach (IPOM) in 41 hernias. RESULTS: Conversion into open surgery was necessary in 7% of the patients. There was no postoperative death. The postoperative morbidity rate was 10%. The average hospital stay was three days. With a 1 to 5 year follow-up, 4% of the 94% of the patients who answered the questionnaire showed a recurrence (3% in the extra-peritoneal group; 4% in the trans abdomino-preperitoneal group; 10% in the intra-abdominal group). CONCLUSION: Laparoscopic hernioplasty seems as efficient as traditional hernoplasty with the advantages of mini-invasive surgery. The extra-peritoneal approach was preferred and performed in most cases of this series. The intra-peritoneal approach was abandoned.

[What place for endoscopic sphincterotomy in treatment of acute pancreatitis?]. / Quelle place pour la sphinctérotomie endoscopique dans le traitement des pancréatites aiguës?

STUDY AIM: A prospective study was undertaken in order to evaluate the effects of endoscopic sphincterotomy on the evolution of biliary and idiopathic acute pancreatitis. PATIENTS AND METHODS: Among 320 patients with acute pancreatitis observed from 1986 to 1996, 118 were excluded from the study for etiological reasons and 137 were included for an endoscopic sphincterotomy within 72 hours from their admission. There were nine technical failures and 128 endoscopic sphincterotomies were performed. Sixty-five eligible patients were not included for logistic problems or patients' refusal; they can be considered as a "control group". RESULTS: The mortality rate of endoscopic sphincterotomy was 0 and the morbidity rate 2.1%. The mortality rate of acute pancreatitis was 3.1% in the sphincterotomy group vs 7.6% in the control group (P = 0.1) (NS) and the morbidity rate 25% versus 32% (P > or = 0.1) (NS). CONCLUSION: These results suggest that endoscopic sphincterotomy could be beneficial in acute biliary or idiopathic pancreatitis but they are not statistically significant. Endoscopic sphincterotomy does not increase the severity of acute pancreatitis and can be considered particularly in cases of gallstone pancreatitis but it should be performed less than 48 hours after the onset of acute pancreatitis.