Clinical features and outcomes of patients with pancreatic cancer requiring unplanned medical ICU admission: A retrospective multicenter study.

BACKGROUND: We sought to describe the reasons for intensive care unit (ICU) admission and outcomes of patients with pancreatic cancer requiring unplanned medical ICU admission. PATIENTS AND METHODS: Retrospective cohort study in five ICUs from 2009 to 2020. All patients with pancreatic cancer admitted to the ICU were included. Patients having undergone recent surgery were excluded (< 4 weeks). RESULTS: 269 patients were included. Tumors were mainly adenocarcinoma (90%). Main reason for admission was sepsis/septic shock (32%) with a biliary tract infection in 44 (51%) patients. Second reason for admission was gastrointestinal bleeding (28%). ICU and 3-month mortality rates were 26% and 59% respectively. Performance status 3-4 (odds ratio OR 3.58), disease status (responsive/stable -ref-, newly diagnosed OR 3.25, progressive OR 5.99), mechanical ventilation (OR 8.03), vasopressors (OR 4.19), SAPS 2 (OR 1.69) and pH (OR 0.02) were independently associated with ICU mortality. Performance status 3-4 (Hazard ratio HR 1.96) and disease status (responsive/stable -ref-, newly diagnosed HR 2.67, progressive HR 4.14) were associated with 3-month mortality. CONCLUSION: Reasons for ICU admissions of pancreatic cancer patients differ from those observed in other solid cancer. Short- and medium-term mortality are strongly influenced by performance status and disease status at ICU admission.

Prehabilitation in hepato-pancreato-biliary surgery: A systematic review and meta-analysis. A necessary step forward evidence-based sample size calculation for future trials.

INTRODUCTION: Prehabilitation is defined as preoperative conditioning of patients in order to improve post-operative outcomes. Some studies showed an increase in functional recovery following colorectal surgery, but its effect in hepato-pancreato-biliary (HPB) surgery is unclear. The aim of this study was to realize a systematic literature review and meta-analysis on the current available evidence on prehabilitation in HPB surgery. MATERIALS AND METHODS: A systematic review and a metanalysis were carried out on prehabilitation (physical, nutritional and psychological interventions) in HPB surgery (2009-2019). Assessed outcomes were postoperative complications, length of stay (LOS), 30-day readmission, and mortality. MAIN RESULTS: Four studies among the 191 screened were included in this systematic review (3 randomized controlled trials, 1 case-control propensity score study), involving 419 patients (prehabilitation group, n=139; control group, n=280). After pooling, no difference was observed on LOS ((-4.37 days [95% CI: -8.86; 0.13]) or postoperative complications (RR 0.83 [95%CI: 0.62; 1.10]), reported by all the included studies. Two trials reported on readmission rate, but given the high heterogeneity, a meta-analysis was not realized. No deaths were reported among the included studies. CONCLUSION: No effect of prehabilitation programs in HPB surgery was observed on LOS or postoperative complications rate. Future trials with standardized outcomes of measure, and adequately powered samples calculations are thus required. PROSPERO REGISTRATION: CRD42020165218.

Time from first seen in specialist care to surgery does not influence survival outcome in patients with upfront resected pancreatic adenocarcinoma.

BACKGROUND: This study evaluated the impact of time to surgery (TTS) on overall survival (OS), disease free survival (DFS) and postoperative complication rate in patients with upfront resected pancreatic adenocarcinoma (PA). METHODS: We retrospectively included patients who underwent upfront surgery for PA between January 1, 2004 and December 31, 2014 from four French centers. TTS was defined as the number of days between the date of the first consultation in specialist care and the date of surgery. DFS for a 14-day TTS was the primary endpoint. We also analyzed survival depending on different delay cut-offs (7, 14, 28, 60 and 75 days). RESULTS: A total of 168 patients were included. 59 patients (35%) underwent an upfront surgery within 14 days. Patients in the higher delay group (> 14 days) had significantly more vein resections and endoscopic biliary drainage. Adjusted OS (p = 0.44), DFS (p = 0.99), fistulas (p = 0.41), hemorrhage (p = 0.59) and severe post-operative complications (p = 0.82) were not different according to TTS (> 14 days). Other delay cut-offs had no impact on OS or DFS. DISCUSSION: TTS seems to have no impact on OS, DFS and 90-day postoperative morbidity.

Microwave Thermoablation of Colorectal Liver Metastases Close to Large Hepatic Vessels Under Pringle Maneuver Minimizes the "Heat Sink Effect".

BACKGROUND: Liver resection and thermoablation are the mainstay of the surgical management of colorectal liver metastases (CRLM). The main limitation of thermoablation is the "heat-sink" effect for nodules next to large vessels. Herein, we report the preliminary results of microwave ablation (MWA) with associated Pringle maneuver to overcome this flaw. METHODS: From November 2017, we performed intraoperative MWA with Pringle maneuver for nodules ≤3 cm with immediate proximity to large vessels (distance ≤ 5 mm, diameter ≥ 3 mm). We collected characteristics of nodules, surgical procedures and postoperative morbidity. Diameter of the ablation area, especially the ablative minimal margin, was calculated for each nodule. Recurrence was also evaluated. RESULTS: Nineteen patients underwent MWA with Pringle maneuver for 23 nodules. Nineteen (83%) ablated nodules were located in segments VI, VII and VIII, and one nodule was in segment I. Median size of nodules was 15 mm (10-21). No deaths occurred. Six patients (38%) experienced complications, among them only one was subsequent to the thermal ablation. Ablative minimal margin was ≥5 mm for 19 (83%) nodules. Margin was not sufficient for four nodules, among them only 2/23 cases (8.7%) of in situ recurrence occurred after 12 months of median follow-up. CONCLUSIONS: In this preliminary study, MWA with Pringle maneuver was associated with a low related morbidity rate and favorable oncological outcome, especially when the radiological minimal margin was sufficient.

Postoperative collections after liver surgery: Risk factors and impact on long-term outcomes.

INTRODUCTION: Postoperative collection (PC) can occur after liver surgery, but little is known on their impact on short and long-term outcomes. The aim of this study was to analyse factors predicting the occurrence of PC, the need of drainage and their impact on oncologic outcomes. METHODS: This single-center, cohort-study included adult patients undergoing liver surgery between 2008 and 2017. The primary objective was to determine variables associated with PC occurrence defined by fluid collection on postoperative day-7 CT scan. Secondary objectives were factors predicting drainage requirement, and predictors of overall survival. RESULTS: During the study period 395 patients were included: 53.6% of them (n=210) developed a PC with 12% (n=49) requiring drainage. Variables associated to the occurrence of PC were body mass index>35kg/m2 (OR 8.09, 95%CI (1.50,43.60) P=0.015) and extension of liver surgery (major vs. minor, OR 1.96, 95% CI (1.05,3.64) P<0.034) while laparoscopic approach was associated to a protective role (OR 0.35, 95%CI (0.18,0.67) P=0.001) in the multivariate analysis. The presence of a PC requiring treatment was associated to long-term mortality (OR:1.85, 95% CI (1.15, 2.97) P<0.01) in patients with malignant disease. CONCLUSIONS: Patients undergoing to major open liver surgery with BMI>35kg/m2 have an increased risk to develop a PC: this target population need a systematic imaging in the postoperative period, even if the indication for drainage should be guided by clinical symptoms. Last, the presence of PC requiring treatment has a negative impact on overall survival among patients treated for malignant disease.

Sequential treatment of rupture of pseudoaneurysm of hepatic artery with peritoneal patch and radiological embolization.

Bleeding after pancreatico-duodenectomy (PD) is a serious complication with high rates of morbidity and mortality. Interventional radiology techniques' using embolization and/or stenting is the optimal management. In case of hemodynamic instability, surgical treatment is mandatory, but its mortality rate is considerable. Herein, we report the management of massive bleeding in a 52-year-old-male patient, 3 weeks after PD. The patient suffered severe hemorrhage with two cardiac arrests and surgical treatment was performed immediately after resuscitation. A defect in the distal part of the hepatic artery was repaired using a peritoneal patch. A postoperative CT scan confirmed bleeding control and the presence of a pseudoaneurysm within the patch area. The second step of the treatment was to perform selective embolization. The course was uneventful, and the patient was discharged 6 weeks later.

Pancreatic mucinous cystadenoma doubly complicated by acute pancreatitis and retroperitoneal rupture.

Mucinous cystadenomas are the most frequent cystic benign tumors of the pancreas. They are characterized by a malignant potential. Acute pancreatitis is their most common complication. This manuscript reports a unique complication of mucinous cystadenomas of the pancreas: retroperitoneal rupture associated to acute pancreatitis. After resuscitation, the patient underwent surgery. A cystic mass of the pancreas tail with retroperitoneal rupture was found. Splenopancreatectomy was performed. Outcomes were straightforward. After 3 years of follow-up, no signs of recurrence are highlighted.

A strangled hernia through the Winslow's hiatus: about a rare situation.

Winslow's hiatus hernia is the rarest of the internal hernias. Its diagnosis is difficult and requires an urgent laparotomy to avoid necrosis of the incarcerated loop or even the death of the patient. We report the case of a patient operated urgently for acute intestinal obstruction caused by a strangled hernia through the Winslow's hiatus. A reduction by traction of the hernia was undertaken. Rapid management of this pathology is important using clinical and radiographical elements.

Adult intussusceptions: Clinical presentation, diagnosis and therapeutic management.

BACKGROUND: Adult intussusception is a rare clinical entity. It is an uncommon cause of intestinal obstruction in adult. It often presents with nonspecific symptoms and preoperative diagnosis remains difficult. The purpose of this study was to determine the clinical entity and surgical approach of adult intussusception. METHODS: We have conducted a retrospective descriptive study starting from 2006 until 2014. We reviewed data for all patients that had been admitted to our department for intestinal intussusception. RESULTS: Eight consecutive patients were admitted to our department. The mean age was 48 years old (20-71). The sex ratio was 0,6. The clinical presentation was acute in 5 cases. A computed tomography was performed in 6 cases. The diagnosis of gastrointestinal intussusception was made preoperatively in 100% of patients. All patients underwent surgery. An organic lesion was identified in 100% of the cases. In all cases, resection of the intussuscepted intestinal loop was done without intestinal reduction. All patients were well followed up and recurrences have been documented. CONCLUSION: In adults, intussusception is usually secondary to an organic cause. In the absence of signs of severity, etiologic diagnosis based on CT allows the diagnosis of the intussusception and sometimes can detect the causal lesion. Therapeutic sanction of intussusception is surgery and there is more emphasis towards resection without reduction.