Enucleation for sporadic non-functioning pancreatic neuroendocrine tumors larger than 2 centimeters is associated with equivalent morbidity and survival compared to smaller tumors: a multi-institutional study.

INTRODUCTION: Non-functioning pancreatic neuroendocrine tumor (NF-PanNET) ≤ 2 cm can be observed or resected. Surgery remains recommended for NF-PanNET > 2 cm but its extent, enucleation (EN) versus formal resection, remains controversial. METHODS: Multicentric retrospective cohort of sporadic NF-PanNET patients treated with EN. Short and long-term outcomes were compared according to tumor size on imaging ≤ 2 cm vs > 2 cm. RESULTS: 131patients underwent EN for NF-PanNET, including 103 (79.0%) ≤ 2 cm and 28 (21.0%) > 2 cm (extremes, 4-55 mm). Patients' characteristics were comparable, and tumor characteristics only differed in their diameter. Clavien III-IV complications were similar (18.4% vs 17.9%, p= 1.00) with one death in NF-PanNET ≤ 2cm. Grade B/C pancreatic fistula were comparable (16.5% vs 10.7%, p= 0.850). In NF-PanNET > 2cm there were more pT2/3 stage tumors (85.7% vs 21.4%, p<0.001), similar rates of grade G2/3 tumors (25% vs 16.5%, p= 0.408) with a median Ki67 of 2 (IQR: 1-3), and of lymphovascular and perineural invasions. Lymph node picking was done in 46 (35.1%) patients, with a higher median number of harvested lymph nodes in NF-PanNET > 2 cm (4 vs 3, p= 0.01). All were pN0. R0 resection rate (78.6% vs 82.5%, respectively; p= 0.670) was equivalent. Five-year overall (100% vs 99%, p= 0.602) and 10-year disease-free (96% vs 92%, respectively; p= 0.532) survivals were comparable. CONCLUSIONS: EN for selected NF-PanNET > 2 cm carries equivalent morbidity, overall and disease-free survivals compared to those observed with NF-PanNET ≤ 2 cm.

Management of Pathogenic CDH1 Variant Carriers Within the FREGAT Network: A Multicentric Retrospective Study.

OBJECTIVE: To describe the management of pathogenic CDH1 variant carriers (pCDH1vc) within the FREGAT (FRench Eso-GAsTric tumor) network. Primary objective focused on clinical outcomes and pathological findings, Secondary objective was to identify risk factor predicting postoperative morbidity (POM). BACKGROUND: Prophylactic total gastrectomy (PTG) remains the recommended option for gastric cancer risk management in pCDH1vc with, however, endoscopic surveillance as an alternative. METHODS: A retrospective observational multicenter study was carried out between 2003 and 2021. Data were reported as median (interquartile range) or as counts (proportion). Usual tests were used for univariate analysis. Risk factors of overall and severe POM (ie, Clavien-Dindo grade 3 or more) were identified with a binary logistic regression. RESULTS: A total of 99 patients including 14 index cases were reported from 11 centers. Median survival among index cases was 12.0 (7.6-16.4) months with most of them having peritoneal carcinomatosis at diagnosis (71.4%). Among the remaining 85 patients, 77 underwent a PTG [median age=34.6 (23.7-46.2), American Society of Anesthesiologists score 1: 75%] mostly via a minimally invasive approach (51.9%). POM rate was 37.7% including 20.8% of severe POM, with age 40 years and above and low-volume centers as predictors ( P =0.030 and 0.038). After PTG, the cancer rate on specimen was 54.5% (n=42, all pT1a) of which 59.5% had no cancer detected on preoperative endoscopy (n=25). CONCLUSIONS: Among pCDH1vc, index cases carry a dismal prognosis. The risk of cancer among patients undergoing PTG remained high and unpredictable and has to be balanced with the morbidity and functional consequence of PTG.

Splenic volume and splenic vein diameter are independent pre-operative risk factors of portal vein thrombosis after splenectomy: a retrospective cohort study.

BACKGROUND: Portal vein thrombosis (PVT) is a common complication following splenectomy. It affects between 5 and 55% of patients undergoing surgery with no clearly defined pre-operative risk factors. The aim of this study was to determine the pre-operative risk factors of PVT. PATIENTS AND METHOD: Single centre, retrospective study of data compiled for every consecutive patient who underwent splenectomy at Toulouse University Hospital between January 2009 and January 2019. Patients with pre- and post-surgical CT scans have been included. RESULTS: 149 out of 261 patients were enrolled in the study (59% were males, mean age 52 years). The indications for splenectomy were splenic trauma (30.9%), malignant haemopathy (26.8%) and immune thrombocytopenia (8.0%). Twenty-nine cases of PVT (19.5%) were diagnosed based on a post-operative CT scan performed on post-operative day (POD) 5. Univariate analysis identifies three main risk factors associated with post-operative PVT: estimated splenic weight exceeding 500 g with an OR of 8.72 95% CI (3.3-22.9), splenic vein diameter over 10 mm with an OR of 4.92 95% CI (2.1-11.8) and lymphoma with an OR of 7.39 (2.7-20.1). The role of splenic vein diameter with an OR of 3.03 95% CI (1.1-8.6), and splenic weight with an OR of 5.22 (1.8-15.2), as independent risk factors is confirmed by multivariate analysis. A screening test based on a POD 5 CT scan with one or two of these items present could indicate sensitivity of 86.2% and specificity of 86.7%. CONCLUSION: This study suggests that pre-operative CT scan findings could predict post-operative PVT. A CT scan should be performed on POD 5 if a risk factor has been identified prior to surgery.

Regenerative medicine for digestive fistulae therapy: Benefits, challenges and promises of stem/stromal cells and emergent perspectives via their extracellular vesicles.

Despite current management strategies, digestive fistulae remain extremely debilitating complications associated with significant morbidity and mortality, generating a need to develop innovative therapies in these indications. A number of clinical trials and experimental studies have thus investigated the potential of stem/stromal cells (SCs) or SC-derived extracellular vesicles (EVs) administration for post-surgical and Crohn's-associated fistulae. This review summarizes the physiopathology and current standards-of-care for digestive fistulae, along with relevant evidence from animal and clinical studies regarding SC or EV treatment for post-surgical digestive fistulae. Additionally, existing preclinical models of fistulizing Crohn's disease and results of SC therapy trials in this indication will be presented. The optimal formulation and administration protocol of SC therapy products for gastrointestinal fistula treatment and the challenges for a widespread use of darvadstrocel (Alofisel) in clinical practice will be discussed. Finally, the potential advantages of EV therapy and the obstacles towards their clinical translation will be introduced.

Are gastric metastases of renal cell carcinoma really rare? A case report and systematic review of the literature.

INTRODUCTION: Renal cell carcinoma (RCC) represents above 3 % of all cancers. At diagnosis, above 25 % of patients with RCC present an advanced disease. Gastric metastasis of RCC is associated with poor outcome. We report the case of a patient treated for a gastric metastasis of RCC and we conducted a systematic review of the literature to report all published cases of RCC patients with gastric metastasis. CASE PRESENTATION: In December 2010, a 61-year-old man was treated by open partial nephrectomy for a localized right clear cell RCC. In September 2018, a metachronous gastric metastasis was found on CT scan. The lesion was located on the lesser curvature of the stomach, measuring 4.5 cm long axis. No other secondary lesions were identified. A laparoscopic wedge resection, converted to laparotomy was performed. Two years later, in September 2020, a CT scan was performed, revealing a 17 mm adenopathy behind the hepatic hilum and a surgical management was performed, including a lymph node dissection of the hepatic hilum and the hepatic artery. Actually, he remains healthy. CLINICAL DISCUSSION AND CONCLUSION: Our systematic review suggests that solitary gastric metastasis of RCC are scarce. In comparison of patients with multiple metastatic sites, the median survival of patients with solitary gastric metastasis is longer.

Management of anastomotic biliary stricture after liver transplantation and impact on survival.

BACKGROUND: Anastomotic biliary strictures (AS) is the main surgical complication after liver transplantation. The aims of this study are to investigate the risk factors of AS, its management and its impact on overall survival and survival of the graft. METHODS: All patients who had received a liver transplantation with duct-to-duct anastomosis at Toulouse University Hospital between 2010 and 2016 were included. RESULTS: Of 225 included patients, 56 (24.9%) presented with AS. The median time to discovery of AS was 83 days and 69.6% of the AS appeared within 6 months. Transplantation in critically ill patients, with a liver score >800 points, was an independent predictive factor of survival (P = 0.003). The first-line treatment was endoscopic (87.5%), with a success rate of 79.6% and a median of 4 procedures per patient in 12 months. In cases of failure of endoscopic therapy, percutaneous treatment had a high failure rate (50%). AS had no impact in terms of overall survival or in terms of graft survival. CONCLUSION: AS do not have any repercussions on patient or graft survival, requiring long endoscopic treatment with multiple procedures. In the event of failure of this first-line endoscopic treatment, it seems preferable to turn directly towards surgical repair.