Minimally invasive versus open radical antegrade modular pancreatosplenectomy for pancreatic ductal adenocarcinoma: an entropy balancing analysis.

BACKGROUND: The safety and efficacy of minimally invasive radical antegrade modular pancreatosplenectomy (MI-RAMPS) remain to be established in pancreatic cancer (PDAC) METHODS: Eighty-five open (O)-RAMPS were compared to 93 MI-RAMPS. The entropy balance matching approach was used to compare the two cohorts, eliminating the selection bias. Three models were created. Model 1 made O-RAMPS equal to the MI-RAMPS cohort (i.e., compared the two procedures for resectable PDAC); model 2 made MI-RAMPS equal to O-RAMPS (i.e., compared the two procedures for borderline-resectable PDAC); model 3, compared robotic and laparoscopic RAMPS. RESULTS: O-RAMPS and MI-RAMPS showed "non-small" differences for BMI, comorbidity, back pain, tumor size, vascular resection, anterior or posterior RAMPS, multi-visceral resection, stump management, grading, and neoadjuvant therapy. Before reweighting, O-RAMPS had fewer clinically relevant postoperative pancreatic fistulae (CR-POPF) (20.0% vs. 40.9%; p = 0.003), while MI-RAMPS had a higher mean of lymph nodes (25.7 vs. 31.7; p = 0.011). In model 1, MI-RAMPS and O-RAMPS achieved similar results. In model 2, O-RAMPS was associated with lower comprehensive complication index scores (MD = 11.2; p = 0.038), and CR-POPF rates (OR = 0.2; p = 0.001). In model 3, robotic-RAMPS had a higher probability of negative resection margins. CONCLUSION: In patients with anatomically resectable PDAC, MI-RAMPS is feasible and as safe as O-RAMPS.

Levels of Robotic Mesopancreas Dissection According to Malignancy and Vascular Anatomy: What Surgeons Need to Know.

INTRODUCTION: The robotic approach is attracting increasing interest among the surgical community, and more and more series describing robotic pancreatoduodenectomy have been reported. Thus, surgeons performing robotic pancreatoduodenectomy should be confident with this critical step's potential scenarios. MATERIALS AND METHODS: According to Yosuke et al., there are three different levels of mesopancreas dissection. We describe the main steps for a safe mesopancreas dissection by robotic approach. RESULTS: This multimedia article provides, for the first time in literature, a comprehensive step-by-step overview of the mesopancreas dissection during robotic pancreatoduodenectomy (PD) and its three different levels according to tumor type. CONCLUSIONS: Through the tips and indications presented in this multimedia article, we aim to familiarize surgeons with the mesopancreas dissections levels according to type of malignancy and vascular anatomy.

Atrial Flutter After Radiofrequency Ablation for Barrett's Esophagus: A Case Report.

BACKGROUND Barrett's esophagus (BE) is a metaplastic change in the normal esophageal squamous epithelium and is a well-recognized precursor of esophageal adenocarcinoma (EAC). Nowadays, focal radiofrequency ablation is a valid technique for BE treatment by inducing a superficial and focal thermic destruction of metaplastic tissues. According to the literature, the most frequent patient-related adverse events of this procedure are esophageal iatrogenic stenosis, mucosal laceration or perforation of the esophagus, chest pain, and odynophagia/dysphagia. Postoperative heart rhythm abnormalities have been reported very rarely. CASE REPORT A 74-year-old patient with HE was treated by radiofrequency ablation (RFA) with the Barrx™ catheter system. He had 2 symptomatic episodes of atrial flutter in the immediate postoperative period requiring an external electrical cardioversion to induce a return to sinus cardiac rhythm. After atrial flutter ablation, 2 more radiofrequency procedures were performed, without adverse events. A laparoscopic Nissen fundoplication was carried out with complete endoscopic and histologic eradication of BE after 12-month follow-up. To the best of our knowledge, this is the first reported case of atrial flutter after esophageal RFA. Different mechanisms acting on an anatomic predisposing substrate can potentially play a role in starting atrial flutter, and include inflammation, autonomic activation, and myocardial injury. CONCLUSIONS The occurrence of this new type of adverse effect could potentially modify indications and postoperative monitoring of RFA treatment for BE. Endoscopists should know the possibility of this procedural complication in high-risk patients and they should propose alternative techniques or implement close cardiac monitoring in the postoperative period.

Multi-visceral resection for left-sided pancreatic ductal adenocarcinoma: a multicenter retrospective analysis from European countries.

BACKGROUND: Due to delayed diagnosis and a lower surgical indication rate, left-sided pancreatic ductal adenocarcinoma (PDAC) is often associated with a poor prognosis in comparison to pancreatic head tumors. Multi-visceral resections (MVR) associated with distal pancreatectomy could be proposed for patients presenting with locally infiltrating disease. METHODS: We retrospectively analyzed a multi-centric cohort of left-sided PDAC patients operated on from 2009 to 2020. Thirteen European high-volume HPB centers participated in this study. We analyzed patients who underwent distal pancreatectomy (DP) associated with MVR and compared them to standard DP patients. RESULTS: Among 258 patients treated curatively for PDAC of the body and tail, 28 patients successfully underwent MVR. A longer operative time was observed in the MVR group (295 min +/- 74 vs. 250 min +/- 96, p= 0.248). The post-operative complication rate was comparable between the two groups (46.4% in the MVR group vs. 62.2% in the control group, p= 0.108). The incidence of positive margin (R1) was similar between the two groups (28.6% vs. 26.6%; p=0.827). After a median follow-up of 25 (9-111) months, overall survival was comparable between the two groups (p= 0.519). CONCLUSIONS: Multi-visceral resection in left-sided pancreatic ductal adenocarcinoma is safe and feasible and should be considered in selected cases as it seems to provide acceptable surgical and oncological outcomes.

Littoral cell angioma discovered after splenectomy in a patient with non-Hodgkin lymphoma and melanoma. Case report and review.

BACKGROUND: Littoral cell angioma (LCA) is a rare vascular primary tumor of the spleen with no more than 440 cases described so far. Although often seen as benign, it is described to have malignant potential and to be associated with other immunologic disorders or malignancies. CASE PRESENTATION: We present the case of LCA in a 75-year old man with a concomitant non-Hodgkin lymphoma and medical history of malign melanoma. The tumor was discovered incidentally after splenectomy for splenomegaly and refractory thrombocytopenia. The post-operative period was uneventful. CONCLUSION: Our case is the first to report an association of LCA with both lymphoma and melanoma thus far. It emphasizes the need for a thorough total body examination for synchronous diseases and close follow-up to reveal associated malignancies or immunologic disorders. Further research is required to identify etiologic and pathogenetic mechanisms behind this tumor and a common basis between the three diseases. KEY WORDS: Littoral Cell Angioma, Neoplasm, Splenectomy, Solid Spleen Tumor.

Superior Mesenteric Artery First Approach for Minimally Invasive Pancreaticoduodenectomy: A Step-By-Step Surgical Technique Video.

INTRODUCTION: In the past decade, minimally invasive pancreaticoduodenectomy has been gaining interest. However, minimally invasive pancreaticoduodenectomy remains technically challenging and is associated with a steep learning curve. Additionally, the operating surgeon should be cognizant of replicating the same oncological steps as observed in the typical open approach. In view of this, there exist various maneuvers that are designed to achieve negative margins and a safer mesopancreatic dissection. One of these techniques is the superior mesenteric artery first approach, which is garnering interest among pancreatic surgeons. MATERIAL AND METHODS: According to existing literature, there are several superior mesenteric artery dissections approaches. We describes 5 different minimally invasive approaches. RESULTS: This multimedia manuscript provide, for the first time in literature, a comprehensive step-by-step overview of the superior mesenteric artery first approach for minimally invasive pancreaticoduodenectomy by a team of expert surgeons from various international institutions. CONCLUSIONS: Through the tips and indications presented in this article, we aim to guide the choice of this approach according to tumor location, type of minimally invasive approach and the operating surgeon's experience and increase familiarity with such a complex procedure.

Minimally invasive pancreatic anastomosis after pancreaticoduodenectomy: multi-institutional step by step video description of the technique.

Minimally invasive pancreaticoduodenectomy (PD) is attracting increased interest in the pancreatic surgical community with more and more teams reporting their experience worldwide. The pancreatic anastomosis (PA) is one of the key steps and challenging manoeuvre of this procedure. Since the introduction of the minimally invasive approach for PD, several PA types have been proposed, ranging from high to low complexity, but none of them have been proven unequivocally superior to the others. Therefore, definitive consensus has not been reached yet. In the present multimedia manuscript, we report the most commonly adopted minimally invasive PA and we propose a "complexity classification" to guide the choice accordingly to different characteristics of the pancreatic stump. We describe five possible different PA that might be tailored to each different case, depending mainly on texture of pancreatic stump (soft/hard, lean/fatty) and the size and visibility of main duct. This manuscript presents a step-by-step portfolio of the most commonly used mini-invasive PA. This technique requires experience in pancreatic surgery and advanced minimally invasive skills. Knowledge of and proficiency in different types of PA could help reducing the incidence of postoperative pancreatic fistula.

Real robotic total mesopancreas excision (TMpE) assisted by hanging manoeuver (HM): Standardised technique.

BACKGROUND: Pancreaticoduodenectomy (PD) is one of the most demanding interventions for digestive surgeons. R0 resection is a key point for the overall survival and disease-free survival. Total mesopancreas excision (TMpE) has been described by laparotomy but laparoscopy did not provide good results probably because of the technical difficulties of the approach. We propose a standardised total robotic approach. METHODS: In this step-by-step technical description, we propose as example, a case of a 53-year-old man with a pancreatic head adenocarcinoma with doubts about the invasion of the mesopancreas surrounding superior mesenteric artery. The mesopancreas hanging manoeuver allows us to perform a TMpE. RESULTS: The surgery performed was a robotic artery first pancreaticoduodenectomy with TMpE. The pathological result was pancreatic ductal adenocarcinoma pT2, N1 (1/23), M0, V0, L0, Pn0, R0. CONCLUSIONS: Robotic approach is safe, effective and reproductible. Through a standardised technique, it may overcome some of the technical difficulties of laparoscopic PD.

The Oncologic Impact of Pancreatic Fistula After Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma of the Body and the Tail: A Multicenter Retrospective Cohort Analysis.

OBJECTIVES: The aim of this study was to assess the impact of clinically relevant postoperative pancreatic fistula (CR-POPF) on patient disease-specific survival and recurrence after curative distal pancreatectomy (DP) for pancreatic cancer. DESIGN: This was a retrospective case-control analysis. METHODS: We examined the data of adult patients with a diagnosis of pancreatic ductal adenocarcinoma (PDAC) of the body and tail of the pancreas undergoing curative DP, over a 10-year period in 12 European surgical departments, from a prospectively implemented database. RESULTS: Among the 382 included patients, 283 met the strict inclusion criteria; 139 were males (49.1%) and the median age of the entire population was 70 years (range 37-88). A total of 121 POPFs were observed (42.8%), 42 (14.9%) of which were CR-POPFs. The median follow-up period was 24 months (range 3-120). Although poorer in the POPF group, overall survival (OS) and disease-free survival (DFS) did not differ significantly between patients with and without CR-POPF (p = 0.224 and p = 0.165, respectively). CR-POPF was not significantly associated with local or peritoneal recurrence (p = 0.559 and p = 0.302, respectively). A smaller percentage of patients benefited from adjuvant chemotherapy after POPF (76.2% vs. 83.8%), but the difference was not significant (p = 0.228). CONCLUSIONS: CR-POPF is a major complication after DP but it did not affect the postoperative therapeutic path or long-term oncologic outcomes. CR-POPF was not a predictive factor for disease recurrence and was not associated with an increased incidence of peritoneal or local relapse. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT04348084.

Laparoscopic repeat surgery for gastro-oesophageal reflux disease: Results of the analyses of a cohort study of 117 patients from a multicenter experience.

BACKGROUND: Short and long-term outcomes after repeat anti-reflux surgery (RARS) are still debated and generally not considered as satisfying as after primary anti-reflux surgery (PARS). The aim of this study was to evaluate functional outcomes after RARS and risk factors associated to intra-operative and post-operative complications. METHODS: This is a multicenter retrospective survey from four European laparoscopic centers. Patients who underwent elective RARS from January 2005 to October 2017 for dysphagia or for persistent reflux disease refractory to medical treatment were analyzed. Data on demographic characteristics, including type and timing of previous operations as well as intra-operative details (surgical technique, type of RARS, conversion to open surgery, prosthetic material placement) were collected. Patients who underwent operations in the emergency setting, interventions mixed with bariatric procedures and PARS performed in other surgical departments were not included in this study. Primary endpoint of this study was to evaluate risk factors associated with intraoperative and postoperative complications. Secondary endpoint was to evaluate clinical outcomes and to identify any possible correlation with clinical and surgical parameters. RESULTS: Among 1662 patients who underwent PARS, failure occurred in 174 (10.5%) patients. Repeat surgery was performed in 117 (7%) patients, after a mean time of 80 months (range 4-315). RARS was carried out laparoscopically in 88% of cases. Prosthetic mesh to reinforce hiatoplasty was used in 22.2% of patients. Intra-operative upper gastro-intestinal tract's injuries occurred in 6 (5.1%) patients. Perioperative mortality was nil and 13 (11.1%) patients experienced postoperative complications. Mean length of hospital stay was 9.6 ± 6.4 days. Based on a multivariable analysis, age >70 years (OR 1.074, C.I.95% 1.018-1.133, p = 0.008) and body mass index (BMI) < 23 (OR 0.172, C.I.95% 0.052-0.568, p = 0.004) were independently associated to postoperative complications. After a mean follow-up time of 36 months (range 6-107), 24 (20.5%) patients presented recurrent symptoms. Based on a multivariable analysis, early onset of dysphagia (OR 3.539, C.I.95% 1.254-9.990, p = 0.017), open approach (OR 4.505, C.I.95% 1.314-15.442, p = 0.016) and the use of prosthetic material (OR 2.790, C.I.95% 0.930-8.776, p = 0.047) were significantly associated to good clinical outcomes. CONCLUSIONS: Repeat anti-reflux surgery is a safe and feasible procedure in high-volume centers, with acceptable perioperative outcomes. Long-term results are favorable with a success rate of almost 80%. Advanced age (>70 years) and low BMI (<23 kg/m2) were factor predicting perioperative complications. The use of prosthesis for hiatoplasty was associated to better functional outcomes.

Rare anatomic variation of the hepatic arterial blood supply: case report and literature review.

PURPOSE: Our aim is to present a rare case of anatomic variation of the arterial blood supply to the liver because preoperative knowledge of hepatic vascular variations is mandatory in hepatic surgery and liver transplantation. METHODS: We present a case of unusual arterial blood supply to the liver, a right hepatic artery coming from the splenic artery, associated to a classical common hepatic artery and a left hepatic artery from the left gastric artery. Preoperative diagnosis was made using CT-scan and 3D reconstruction. RESULTS: The right hepatic artery was found behind the portal vein and its diameter showed its importance in the vascularisation of the liver. To our knowledge this type of variation has only twice been described before. The accuracy of the 3D reconstruction allowed us to adopt the best surgical strategy to avoid lesions of the two accessory arteries which proved important sources of blood supply. CONCLUSIONS: Precise preoperative evaluation of liver blood supply has great importance on surgical, transplantation strategy and outcome and rare anatomic variations have to be known to avoid lesions of potentially important arteries. New techniques of 3D reconstruction can ease the preoperative recognition of such difficult anatomic variations.

A retrospective multicenter analysis on redo-laparoscopic anti-reflux surgery: conservative or conversion fundoplication?

BACKGROUND: Nearly 20% of patients who undergo hiatal hernia (HH) repair and anti-reflux surgery (ARS) report recurrent HH at long-term follow-up and may be candidates for redo surgery. Current literature on redo-ARS has limitations due to small sample sizes or single center experiences. This type of redo surgery is challenging due to rare but severe complications. Furthermore, the optimal technique for redo-ARS remains debatable. The purpose of the current multicenter study was to review the outcomes of redo-fundoplication and to identify the best ARS repair technique for recurrent HH and gastroesophageal reflux disease (GERD). METHODS: Data on 975 consecutive patients undergoing hiatal hernia and GERD repair were retrospectively collected in five European high-volume centers. Patient data included demographics, BMI, techniques of the first and redo surgeries (mesh/type of ARS), perioperative morbidity, perioperative complications, duration of hospitalization, time to recurrence, and follow-up. We analyzed the independent risk factors associated with recurrent symptoms and complications during the last ARS. Statistical analysis was performed using GraphPad Prism® and R software®. RESULTS: Seventy-three (7.49%) patients underwent redo-ARS during the last decade; 71 (98%) of the surgeries were performed using a minimally invasive approach. Forty-two (57.5%) had conversion from Nissen to Toupet. In 17 (23.3%) patients, the initial Nissen fundoplication was conserved. The initial Toupet fundoplication was conserved in 9 (12.3%) patients, and 5 (6.9%) had conversion of Toupet to Nissen. Out of the 73 patients, 10 (13%) underwent more than one redo-ARS. At 8.5 (1-107) months of follow-up, patients who underwent reoperation with Toupet ARS were less symptomatic during the postoperative period compared to those who underwent Nissen fundoplication (p = 0.005, OR 0.038). Patients undergoing mesh repair during the redo-fundoplication (21%) were less symptomatic during the postoperative period (p = 0.020, OR 0.010). The overall rate of complications (Clavien-Dindo classification) after redo surgery was 11%. Multivariate analysis showed that the open approach (p = 0.036, OR 1.721), drain placement (p = 0.0388, OR 9.308), recurrence of dysphagia (p = 0.049, OR 8.411), and patient age (p = 0.0619, OR 1.111) were independent risk factors for complications during the last ARS. CONCLUSIONS: Failure of ARS rarely occurs in the hands of experienced surgeons. Redo-ARS is feasible using a minimally invasive approach. According to our study, in terms of recurrence of symptoms, Toupet fundoplication is a superior ARS technique compared to Nissen for redo-fundoplication. Therefore, Toupet fundoplication should be considered in redo interventions for patients who initially underwent ARS with Nissen fundoplication. Furthermore, mesh repair in reoperations has a positive impact on reducing the recurrence of symptoms postoperatively.

Postoperative Infectious Complications Impact Long-Term Survival in Patients Who Underwent Hepatectomies for Colorectal Liver Metastases: a Propensity Score Matching Analysis.

OBJECTIVE: Postoperative complications strongly impact the postoperative course and long-term outcome of patients who underwent liver resection for colorectal liver metastases (CRLM). Among them, infectious complications play a relevant role. The aim of this study was to evaluate if infectious complications still impact overall and disease-free survival after liver resection for CRLM once patients were matched with a propensity score matching analysis based on Fong's criteria. METHODS: A total of 2281 hepatectomies were analyzed from a multicentric retrospective cohort of hepatectomies. Patients were matched with a 1:3 propensity score analysis in order to compare patients with (INF+) and without (INF-) postoperative infectious complications. RESULTS: Major resection (OR = 1.69 (1.01-2.89), p = 0.05) and operative time (OR = 1.1 (1.1-1.3), p = 0.05) were identified as risk factors of infectious complications. After propensity score matching, infectious complications are associated with overall survival (OS), with 1-, 3-, 5-year OS at 94, 81, and 66% in INF- and 92, 66, and 57% in INF+ respectively (p = 0.01). Disease-free survival (DFS) was also different with regard to 1-, 3-, 5-year survival at 65, 41, and 22% in R0 vs. 50, 28, and 17% in INF+ (p = 0.007). CONCLUSION: Infectious complications are associated with decreased overall and disease-free survival rates.

Major Hepatectomy for Colorectal Liver Metastases in Patients Aged Over 80: A Propensity Score Matching Analysis.

BACKGROUND: The aim of this study was to evaluate the results of major hepatectomies for metastasis in elderly colorectal cancer patients, for whom limited data exist in the literature. METHODS: From January 2006 to January 2013, 3,034 patients underwent hepatectomy for colorectal liver metastasis in 32 French surgical centers. Repeat hepatectomies were excluded from the study. Based on a 1: 4 propensity score matching model, 42 patients aged ≥80 (OG) were matched with 168 patients <80 years (YG) in order to obtain 2 well-balanced and homogeneous groups with regards to therapy and prognostic factors. RESULTS: The unmatched cohort consisted of 744 patients (OG: n = 42; YG: n = 702). After PS matching, there was no difference in terms of general morbidity, rates of Dindo-Clavien score ≥III (OG: 16% vs. YG: 21%, p = 0.663), surgical morbidity (OG: 16% vs. YG: 21%, p = 0.663), reoperation (OG:10% vs. YG: 5%, p = 0.263), 90-day mortality (OG: 0% vs. YG:2%, p = 1), and total median hospital stay (OG: 12 vs. YG: 12, p = 0.972). Both groups experienced similar 3- and 5-year overall survival (82 and 82% OG vs.78 and 67% YG) and disease-free survival (40 and 35% OG vs. 45 and 35% YG at 3 and 5 years). CONCLUSIONS: No difference in perioperative and postoperative outcomes and disease-free and overall survival was found. Major hepatectomy in selected octogenarian patients is safe and feasible.

Margin Status is Still an Important Prognostic Factor in Hepatectomies for Colorectal Liver Metastases: A Propensity Score Matching Analysis.

OBJECTIVE: The width of resection margin is still a matter of debate in case of colorectal liver metastasis resection. The aim of this study was to determine the risk factors for R1 resection. Once risk factors had been identified, patients were matched according to Fong's prognostic criteria, in order to evaluate whether R1 resection still remained a negative prognostic factor impacting overall and disease-free survival. METHODS: A total of 1784 hepatectomies were analyzed from a multicentric retrospective cohort of hepatectomies. Patients were compared before and after a 1:1 propensity score analysis in order to compare R0 versus R1 resections according to Fong criteria. RESULTS: Primary tumor nodes found positive after colorectal resection (RR = 1.20, p = 0.02), operative time (> 240 min) (RR = 1.26, p = 0.05), synchronous liver metastasis (RR = 1.27, p = 0.02), pedicle clamping (> 40 min) (RR = 1.52, p = 0.001), lesion size larger than 50 mm (RR = 1.54, p = 0.001), rehepatectomy (RR = 1.68, p = 0.001), more than 3 lesions (RR = 1.69, p = 0.0001), and bilateral lesions (RR = 1.74, p = 0.0001) were identified as risk factors in multivariate analysis. After a 1:1 PSM according to Fong criteria, R1 resection still remained a negative prognostic factor impacting overall and disease-free survival, with 1-, 3-, 5-year OS at 94, 81, and 70% in R0 and 92, 75, and 58% in R1, respectively, (p = 0.008), and disease-free survival (DFS) with 1-, 3-, 5-year survival at 64, 41, and 28% in R0 versus 51, 28, and 18% in R1 (p = 0.0002), respectively. CONCLUSION: Even after using PSM as an oncological prognostic criterion, R1 resection still impacts overall and disease-free survival negatively.

miR-135a-5p-mediated downregulation of protein tyrosine phosphatase receptor delta is a candidate driver of HCV-associated hepatocarcinogenesis.

BACKGROUND AND AIMS: HCV infection is a leading risk factor of hepatocellular carcinoma (HCC). However, even after viral clearance, HCC risk remains elevated. HCV perturbs host cell signalling to maintain infection, and derailed signalling circuitry is a key driver of carcinogenesis. Since protein phosphatases are regulators of signalling events, we aimed to identify phosphatases that respond to HCV infection with relevance for hepatocarcinogenesis. METHODS: We assessed mRNA and microRNA (miRNA) expression profiles in primary human hepatocytes, liver biopsies and resections of patients with HCC, and analysed microarray and RNA-seq data from paired liver biopsies of patients with HCC. We revealed changes in transcriptional networks through gene set enrichment analysis and correlated phosphatase expression levels to patient survival and tumour recurrence. RESULTS: We demonstrate that tumour suppressor protein tyrosine phosphatase receptor delta (PTPRD) is impaired by HCV infection in vivo and in HCC lesions of paired liver biopsies independent from tissue inflammation or fibrosis. In liver tissue adjacent to tumour, high PTPRD levels are associated with a dampened transcriptional activity of STAT3, an increase of patient survival from HCC and reduced tumour recurrence after surgical resection. We identified miR-135a-5p as a mechanistic regulator of hepatic PTPRD expression in patients with HCV. CONCLUSIONS: We previously demonstrated that STAT3 is required for HCV infection. We conclude that HCV promotes a STAT3 transcriptional programme in the liver of patients by suppressing its regulator PTPRD via upregulation of miR-135a-5p. Our results show the existence of a perturbed PTPRD-STAT3 axis potentially driving malignant progression of HCV-associated liver disease.

Real case of primitive embryonal duodenal carcinoma in a young man.

We report here the case of a young man suffering from a rare germ cell tumour. The patient was a 25-year-old man who was referred to our centre for asthenia, stinging epigastric pain, and an iron deficiency anaemia. Gastroscopy revealed a circumferential vegetating lesion on the second portion of the duodenum. The lesion was indurated at the third portion of the duodenum, responsible for a tight stenosis. A computerized tomography-scan of the chest, abdomen and pelvis, and a pancreatic MRI showed a circumferential lesion with a bi-ductal dilatation (i.e., of the common bile duct and Wirsung's duct) without metastatic localisation. The patient underwent a pancreaticoduodenectomy with lymph node dissection including all cellular adipose tissues of the hepatic pedicle from the hepatic common artery and of the retroportal lamina. Histological findings were suggestive of a duodenal embryonal carcinoma with pancreatic infiltration. This is the second published case highlighting the duodenal primitive localisation of an embryonal carcinoma with pancreatic infiltration.

Scale-adaptive supervoxel-based random forests for liver tumor segmentation in dynamic contrast-enhanced CT scans.

PURPOSE: Toward an efficient clinical management of hepatocellular carcinoma (HCC), we propose a classification framework dedicated to tumor necrosis rate estimation from dynamic contrast-enhanced CT scans. Based on machine learning, it requires weak interaction efforts to segment healthy, active and necrotic liver tissues. METHODS: Our contributions are two-fold. First, we apply random forest (RF) on supervoxels using multi-phase supervoxel-based features that discriminate tissues based on their dynamic in response to contrast agent injection. Second, we extend this technique in a hierarchical multi-scale fashion to deal with multiple spatial extents and appearance heterogeneity. It translates in an adaptive data sampling scheme combining RF and hierarchical multi-scale tree resulting from recursive supervoxel decomposition. By concatenating multi-phase features across the hierarchical multi-scale tree to describe leaf supervoxels, we enable RF to automatically infer the most informative scales without defining any explicit rules on how to combine them. RESULTS: Assessment on clinical data confirms the benefits of multi-phase information embedded in a multi-scale supervoxel representation for HCC tumor segmentation. CONCLUSION: Dedicated but not limited only to HCC management, both contributions reach further steps toward more accurate multi-label tissue classification.