How I do it: using a hammock mesh in the reconstruction of inguinal ligament during a wide en-bloc resection of a groin mesenchymal tumor.

PURPOSE: In case of soft tissue sarcomas (STS), an en-bloc resection with safe margins is recommended. To ensure safe removal without tumor rupture, STS of the groin area, retroperitoneal or pelvic mesenchymal tumors may require incision or resection of the inguinal ligament. Solid reconstruction is mandatory to prevent early and late postoperative femoral hernias. We present here a new technique of inguinal ligament reconstruction. METHODS: Between September 2020 and September 2022, patients undergoing incision and/or resection of inguinal ligaments during a wide en-bloc resection of STS of the groin area in the Department of General Surgery in Strasbourg were included. All patients had an inguinal ligament reconstruction with biosynthetic slowly resorbable mesh shaped as a hammock, pre- or intraperitoneally, associated or not with loco-regional pedicled muscular flaps. RESULTS: A total of 7 hammock mesh reconstructions were performed. One or several flaps were necessary in 57% of cases (4 patients): either for inguinal ligament reconstruction only (n = 1), for recovering of femoral vessels (n = 1), and for both ligament reconstruction and defect covering (n = 2). The major morbidity rate was 14.3% (n = 1), related to a thigh surgical site infection due to sartorius flap infarction. After a median follow-up of 17.8 months (range 7-31), there was neither early nor late occurrence of post-operative femoral hernia. CONCLUSIONS: This is a new surgical tool for inguinal ligament reconstruction with the implementation of a biosynthetic slowly resorbable mesh shaped as a hammock, which should be compared to other techniques.

External multicentre validation of pseudomyxoma peritonei PSOGI-Ki67 classification.

BACKGROUND: Pseudomyxoma peritonei (PMP) is a rare malignant disease. Adding of the Ki67 proliferation index to the PSOGI PMP classification provided two different subcategories of the extensive HG-PMP group (HG-PMP ≤15% and HG-PMP >15%) with different survival in a previous unicentric study. This study aims to carry out an external and multicentre validation of this new proposed classification. METHOD: It was a prospective analysis of samples from a historical and international cohort of patients. A representative area with higher cellular density was used to determine the Ki67%. The Ki67 proliferation index (%) was determined in all the HG-PMP patients. A Cox proportional hazard models and multivariable COX models were used. The Kaplan-Meier method and the two-tailed log-rank test were used to analyse the effect of different PSOGI-Ki67 categories on OS and DFS. Its predictive accuracy was analysed using Harrel's C-index and the ROC curve. The calibration was performed using the calibration plots matching. RESULTS: After exclusions, 349 patients were available for analysis. The 5-years OS were 86% for LG-PMP, 59% for HG-PMP≤15, 38% for HG-PMP>15 and 42% for SRC-PMP (p = 0.0001). The 5-years DFS were 49% for LG-PMP, 35% for HG-PMP≤15, 16% for HG-PMP>15 and 18% SRC-PMP (p = 0.0001). The discrimination capability of PSOGI-Ki67 was validated. CONCLUSION: the PSOGI-Ki67 classification discriminates and predicts the OS and DFS in patients with PMP dividing the HG-PMP category into two well-defined sub-categories. The Ki67 proliferation index should be incorporated routinely in the pathology report for these patients.

Do surgical drains reduce surgical site occurrence and infection after incisional hernia repair with sublay mesh? A non-randomised pilot study.

INTRODUCTION: Surgical site occurrence (SSO) and surgical site infection (SSI) are common concerns with incisional hernia repair. Intraoperative drain placement is a common practice aiming to reduce SSO and SSI rates. However, literature on the matter is very poor. The aim of this study is to investigate the role of subcutaneous and periprosthetic drain placement on postoperative outcomes and SSO and SSI rates with incisional hernia repair. METHODS: A non-randomised pilot study was performed between January 2018 and December 2020 and included patients with elective midline or lateral incisional hernia repair with sublay mesh placement. Patients were prospectively included, followed for 1 month and divided into three groups: group 1 without drainage, group 2 with subcutaneous drainage, and group 3 with subcutaneous and periprosthetic drains. Drains were placed at surgeon's discretion. All patients were included in the enhanced recovery program. RESULTS: One hundred and four patients were included. Twenty-four patients (23.1%) did not have drains (group 1), 60 patients (57.7%) had a subcutaneous drain (group 2) and 20 patients (19.2%) had both a subcutaneous and a periprosthetic drains (group 3). SSO rates were significantly different between the 3 groups: 20.8% in group 1, 20.7% in group 2 and 50% in group 3 (p = 0.03). There was no significant difference in deep and superficial SSI rates between the 3 groups. Subgroup analysis revealed that adding a drain in direct contact with the mesh significantly increased SSO rate but did not influence SSI rate. Length of stay was also significantly increased by the presence of a drain, 3.1 ± 1.9 days for group 1; 5.9 ± 4.8 for group 2 and 5.9 ± 2.5 days for group 3 (p < 0.005). CONCLUSION: Drain placement in direct contact with the mesh might increase SSO rate. More studies are necessary to evaluate the actual benefits of drainage after incisional hernia repair.

Why and how to implement an electronic resident's surgical logbook to improve operating-room training? First 5-year feedback from a French center.

INTRODUCTION: The evaluation of general surgery residents' operating room (OR)-training and technical skills progression may be difficult in the absence of a standardized evaluation tool. The aim of this study was to evaluate the impact of the implementation of an electronic "surgical logbook" for general surgery residents. METHODS: A prospective single center study was conducted between May 2015 and October 2020. An electronic logbook was filled by all residents immediately after each surgical procedure and data were prospectively collected and analyzed. RESULTS: Fifty-five students (34 men/21 women) reported their participation to 6917 surgical procedures, which corresponded to 55.5% of all procedures performed in our department. Residents performed the entire procedure as the operating surgeon in 28.5% of cases (n=1963), parts of the procedure as operating surgeon in 32.5% of cases (n=2230) and as operating-assistant in 38.5% (n=2672). Residents were more likely an operating surgeon for the entire procedure when they were assisted by a fellow or a practicing physician than an associate professor or a clinical professor (P<0.001). There was no significant difference in the major morbidity rate between different resident's contribution to the procedure (P=0.14). CONCLUSION: We present here a simple, useful and cost efficient tool which offers easy data collection and reporting that could help improve OR-training, OR-supervision and certification at a local or national level.

Dialkylcarbamoyl chloride-coated versus alginate dressings after pilonidal sinus excision: a randomized clinical trial (SORKYSA study).

BACKGROUND: Disease of the pilonidal sinus is a common condition that affects mainly young adults. Options for management include excision of the sinus tracts, leaving the wound open to heal by secondary intention. The aim of this study was to compare wound healing with dialkylcarbamoyl chloride (DACC)-coated dressings versus alginate dressings. METHODS: This multicentre trial randomized consecutive patients undergoing surgery for pilonidal disease to postoperative wound care with either DACC-coated or alginate dressings. The primary outcome was the proportion of wounds healed after 75 days. Secondary outcomes were the local status of wounds during the healing process, the quality assessment of the dressings by the patient, and the time needed to return to usual activities. RESULTS: A total of 246 patients were included: 120 in the DACC-coated group and 126 in the alginate group. In per-protocol analysis, there were significantly more patients with completely healed wounds after 75 days in the DACC group than in the alginate group: 78 of 103 (75·7 per cent) versus 58 of 97 (60 per cent) respectively (odds ratio 2·55, 95 per cent c.i. 1·12 to 5·92; P = 0·023). During follow-up, wounds with alginate dressings had more fibrin than those with DACC-coated dressings, but the difference was not significant (P = 0·079). There was no difference between the two arms in patients' assessment of the dressings. CONCLUSION: The number of wounds completely healed at 75 days was significantly higher for DACC-coated compared with alginate dressings. However, the preplanned, clinically significant improvement in healing of 20 per cent was not reached. Registration number: NCT02011802 ( https://clinicaltrials.gov/).

ANTECEDENTES: El sinus pilonidal es una afección común que afecta principalmente a adultos jóvenes. Las opciones de tratamiento incluyen la escisión de los trayectos del sinus, dejando la herida abierta para cicatrizar por segunda intención. El objetivo de este estudio fue comparar la cicatrización de heridas con apósitos recubiertos con cloruro de diaquilcarbamoilo (dialkylcarbamoyl chloride, DACC) en comparación con apósitos de alginato. MÉTODOS: En este ensayo multicéntrico se asignó al azar a pacientes consecutivos sometidos a cirugía por sinus pilonidal a uno de los dos brazos: cuidado postoperatorio de heridas con apósitos recubiertos con DACC o con alginato. El criterio de valoración principal fue la proporción de heridas curadas después de 75 días. Los criterios de valoración secundarios fueron el estado local de las heridas durante el proceso de curación, la evaluación de la calidad de los apósitos por parte del paciente y el tiempo necesario para volver a la actividad profesional. RESULTADOS: Se incluyeron un total de 246 pacientes: 120 en el grupo de apósitos recubiertos de DACC y 126 en el grupo de alginato. En el análisis por protocolo, hubo significativamente más pacientes con heridas completamente curadas después de 75 días en el grupo DACC que en el grupo de alginato: 78 de 103 (75,7%) y 58 de 97 (59,7%) respectivamente (razón de oportunidades, odds ratio, OR = 2,55; (1,12; 5,92); P = 0,02)). Durante el seguimiento, las heridas recubiertas con apósitos de alginato tenían más fibrina que las recubiertos con DACC, pero la diferencia no fue significativa (P = 0,08). No hubo diferencias entre los dos brazos en la evaluación realizada por los pacientes de los apósitos. CONCLUSIÓN: El número de heridas completamente curadas a los 75 días fue significativamente mayor con los apósitos recubiertos con DACC en comparación con los apósitos de alginato. Sin embargo, no se alcanzó la mejoría clínicamente significativa preestablecida de una curación del 20%.

Occupational safety of pressurized intraperitoneal aerosol chemotherapy (PIPAC) in an operating room without laminar airflow.

AIM OF THE STUDY: The safety of pressurized intraperitoneal aerosol chemotherapy (PIPAC) is often questioned when newly implemented in an operating room (OR); as it may increase the risk of exposure to cytotoxics for healthcare workers. There are no data on the risk of healthcare exposure in OR without laminar airflow. We aimed to ensure the safety of PIPAC for surgeons and their co-workers for newly implemented procedures in an OR without laminar airflow. PATIENTS AND METHODS: Twenty-six samples with cellulosic wipes from surgeons and co-workers' environmental items and 5 specific polytetrafluoroethylene air-filtered collections were randomly performed for the first 2 cisplatin/doxorubicin-based PIPAC procedures in Strasbourg University Hospital. PIPAC was performed according to previously described safety protocol but without a laminar airflow and with an additional plastic cover and smoke evacuation device. Sampling and analyzes were performed by 2 accredited independent certified organizations. RESULTS: All air measurements were negative for cisplatin and doxorubicin. Only one wipe sample out of 26 was positive for cisplatin (4%) on the outer surgeon's pair of gloves but dosages on the surgeon's inner pair and hands were negative. CONCLUSION: When performed in approved security conditions, even without laminar airflow, PIPAC might seem harmless for surgeons and their co-workers with very limited risk of exposure to cytotoxics.

Can we cure patients with abdominal Desmoplastic Small Round Cell Tumor? Results of a retrospective multicentric study on 100 patients.

BACKGROUND: Despite being associated with a very poor prognosis, long-term survivors across all series of Desmoplastic Small Round Cell Tumor (DSRCT) have been reported. AIM OF THE STUDY: To analyze patients 'characteristics associated with a prolonged survival after DSRCT diagnosis. METHODS: All consecutive patients treated for DSRCT in nine French expert centers between 1991 and 2018 were retrospectively analyzed. Patients with a follow-up of less than 2 years were excluded and cure defined as being disease-free at least 5 years. RESULTS: 100 pts were identified (median age 25 years, 89% male). 27 had distant metastases at diagnosis and 80 pts underwent upfront chemotherapy (CT). 71 pts were operated, 20 pts without prior CT). Surgery was macroscopically complete (CC0/1) in 50 pts. Hyperthermic intraperitoneal Chemotherapy (HIPEC) was administered during surgery in 15 pts 54 pts had postoperative CT and 26 pts had postoperative whole abdomino-pelvic RT (WAP-RT). After a median follow-up of 103 months (range 23-311), the median overall survival (OS) was 25 months. The 1- year, 3-year and 5-year OS rates were 90%, 35% and 4% respectively. 5 patients were considered cured after a median disease-free interval of 100 months (range 22-139). Predictive factors of cure were female sex (HR = 0.49, p = 0.014), median PCI<12 (HR = 0.32, p = 0.0004), MD Anderson stage I (HR = 0.25, p < 0.0001), CC0/1 (HR = 0.34, p < 0.0001), and WAP-RT (HR = 0.36, p = 0.00013). HIPEC did not statistically improve survival. CONCLUSION: Cure in DSRCT is possible in 5% of patients and is best achieved combining systemic chemotherapy, complete cytoreductive surgery and WAP-RT. Despite aggressive treatment, recurrence is common and targeted therapies are urgently needed.

Survival Benefit of the Surgical Management of Retroperitoneal Sarcoma in a Reference Center: A Nationwide Study of the French Sarcoma Group from the NetSarc Database.

BACKGROUND: Guidelines recommend that retroperitoneal sarcoma (RPS) be managed in a reference sarcoma center (RSC), but the benefit remains to be demonstrated. This study investigated the impact of initial surgery performed within the NetSarc network on overall survival (OS). METHODS: NetSarc is a network of 26 RSCs with specialized multidisciplinary tumor boards (MDTs) that is funded by the French NCI. Since 2010, presentation to an MDT and second pathological review are mandatory for sarcoma patients, and data have been collected in a nationwide database. We extracted data for all patients who received surgery in or outside the network and who presented at a NetSarc center (NSC) for primary nonmetastatic RPS between 2010 and 2017. RESULTS: A total of 2945 patients were included: 1078 (36.6%) underwent the first surgery in an NSC, and 1867 (63.4%) in an out-of-network center. The median number of operations at an NSC during the study period was 23 (range: 3-209), and the corresponding median was 1 (range: 1-2) at out-of-network centers. The diagnostic procedures followed significantly more clinical practice guidelines within NetSarc, where there were significantly more first R0 resections [452 (41.9%) vs. 230 (12.3%)]. The OS was significantly superior for patients treated within NetSarc, with a 2-year OS of 87% vs. 70% (p < 0.001). In the multivariate analysis, surgery within an NSC was an independent predictor of OS, with a twofold lower odds ratio of death. CONCLUSIONS: In this national study, surgery for primary RPS within an NSC was associated with a better OS.

[What is the best management for a spermatic cord sarcoma in 2018?] / Quelle prise en charge optimale pour un sarcome du cordon spermatique en 2018 ?

Spermatic cord sarcomas are rare tumors for which the most important is the initial diagnostic procedure. They are frequently misdiagnosed after surgery for inguinal hernia, inguinal lymphadenectomy or testicular malignancy. Any clinical suspicion has to lead to perform imaging with MRI and a core needle biopsy in order to obtain an accurate preoperative diagnosis. Liposarcoma and leiomyosarcoma are the most common histological subtypes in elderly adults, rhabdomyosarcoma in children or in young adults. A CT scan will precede the treatment in order to look for distant metastasis and abdominal involvement. The therapeutic strategy as well as the surgical planning are then adapted to the histological, morphological and prognostic factors. Surgery is the cornerstone for the treatment of spermatic cord sarcoma. The minimum requirements for the surgical procedure are a wide excision of the tumor en bloc with radical orchidectomy, excision of the ipsilateral scrotum and high spermatic cord ligation. It could be enlarged to the anterior abdominal wall and adjacent organs some required a soft tissue flap. Spermatic cord sarcoma and trunk wall sarcoma have the same prognosis for which local recurrence could significantly decrease survival. Consequently, surgeon in charge with these tumors has to be familiar with soft tissue sarcoma and the management of these patients must be carried out under the supervision of a multidisciplinary team within the Netsarc network.

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.

Influence of preoperative life satisfaction on recovery and outcomes after colorectal cancer surgery - a prospective pilot study.

BACKGROUND: Colorectal surgery has an important impact on a patient's quality of life, and postoperative rehabilitation shows large variations. To enhance the understanding of recovery after colorectal cancer, health-related quality of life has become a standard outcome measurement for clinical care and research. Therefore, we aimed to correlate the influence of preoperative global life satisfaction on subjective feelings of well-being with clinical outcomes after colorectal surgery. METHODS: In this pilot study of consecutive colorectal surgery patients, various dimensions of feelings of preoperative life satisfaction were assessed using a self-rated scale, which was validated in French. Both objective (length of stay and complications) and subjective (pain, subjective well-being and quality of sleep) indicators of recovery were evaluated daily during each patient's hospital stay. RESULTS: A total of 112 patients were included. The results showed a negative relationship between life satisfaction and postoperative complications and a significant negative correlation with the length of stay. Moreover, a significant positive correlation between life satisfaction and the combined subjective indicators of recovery was observed. CONCLUSION: We have shown the importance of positive preoperative mental states and global life satisfaction as characteristics that are associated with an improved recovery after colorectal surgery. Therefore, patients with a good level of life satisfaction may be better able to face the consequences of colorectal surgery, which is a relevant parameter in supportive cancer care.

Patterns of care and clinical outcomes in primary oesophageal gastrointestinal stromal tumours (GIST): A retrospective study of the French Sarcoma Group (FSG).

BACKGROUND: Oesophageal GIST (ESOGIST) are very rare tumours requiring special consideration regarding diagnosis, surgical management, and perioperative treatment. METHODS: A retrospective study was conducted across 9 centres in the French Sarcoma Group (FSG) to characterize all patients in the years 2000-2014. RESULTS: Seventeen patients (pts) with primary localized ESOGIST were identified, with median age 69 years (36-81) and 11 females. Eight tumours (T) occurred in the lower third of the oesophagus, five in the oesophageal gastric junction, two in the superior third, and two in the middle third. All pts underwent oesophagoscopy and/or endoscopic ultrasound (EUS) and CT scan. Fifteen had EUS guided biopsy. Nine pts received Imatinib (IM) as initial treatment resulting in six PR, three SD. Tumours were resected in nine pts (53%) (7 upfront, 2 after IM); via enucleation in four (44%) [median size 4 cm], oesophagectomy in five (56%) [median size 10 cm]. Resections were R0 in three pts (33%), R1 in six (66%). Eight pts (47%) had no tumour resection, and one patient was never treated. Six pts received adjuvant IM. With a median follow-up of 24 months (7-101), 11 pts are alive (64.7%), five died (29.4%), one was lost to follow-up. Two pts of 4 pts relapsed following enucleation. CONCLUSIONS: ESOGIST can be reliably identified pre-operatively by EUS-guided biopsy. Surgery for ESOGIST is either enucleation or oesophagectomy depending on tumour size, location, and patient's individual surgical risk. Preoperative IM therapy could improve resectability and should be considered if surgery is contraindicated or would lead to negative impact on the functional status of the patient.

Abdominal desmoplastic small round cell tumor without extraperitoneal metastases: Is there a benefit for HIPEC after macroscopically complete cytoreductive surgery?

BACKGROUND: Desmoplastic Small Round Cell Tumor (DSRCT) is a rare disease affecting predominantly children and young adults and for which the benefit of hyperthermic intraperitoneal chemotherapy (HIPEC) after complete cytoreductive surgery (CCRS) remains unknown. METHODS: To identify patients with DSRCT without extraperitoneal metastases (EPM) who underwent CCRS between 1991 and 2015, a retrospective nation-wide survey was conducted by crossing the prospective and retrospective databases of the French Network for Rare Peritoneal Malignancies, French Reference Network in Sarcoma Pathology, French Sarcoma Clinical Network and French Pediatric Cancer Society. RESULTS: Among the 107 patients with DSRCT, 48 had no EPM and underwent CCRS. The median peritoneal cancer index (PCI) was 9 (range: 2-27). Among these 48 patients, 38 (79%) had pre- and/or postoperative chemotherapy and 23 (48%) postoperative whole abdominopelvic radiotherapy (WAP-RT). Intraperitoneal chemotherapy was administered to 11 patients (23%): two received early postoperative intraperitoneal chemotherapy (EPIC) and nine HIPEC. After a median follow-up of 30 months, the median overall survival (OS) of the entire cohort was 42 months. The 2-y and 5-y OS were 72% and 19%. The 2-y and 5-y disease-free survival (DFS) were 30% and 12%. WAP-RT was the only variable associated with longer peritoneal recurrence-free survival and DFS after CCRS. The influence of HIPEC/EPIC on OS and DFS was not statistically conclusive. CONCLUSION: The benefit of HIPEC is still unknown and should be evaluated in a prospective trial. The value of postoperative WAP-RT seems to be confirmed.

Prognostic factors of hemorrhagic complications after oxaliplatin-based hyperthermic intraperitoneal chemotherapy: Toward routine preoperative dosage of Von Willebrand factor?

BACKGROUND: Oxaliplatin-based hyperthermic intraperitoneal chemotherapy (HIPEC-ox) induces specific morbidity with hemorrhagic complications (HC). The aim of this study was to identify preoperative, intraoperative and postoperative HC predictive factors after HIPEC-ox. METHODS: A prospective single center study that included all consecutive patients treated with curative-intent HIPEC-ox, whatever the origin of peritoneal disease, was conducted. All patients underwent systematic blood tests exploring primary hemostasis and endothelial activation before surgical incision (D0) and on postoperative days 2 (POD2) and 5 (POD5). RESULTS: Between May 2012 and August 2015, 47 patients were enrolled in the study. The overall HC rate was 38%. Major morbidity was significantly higher in patients with HC. Patients presenting HC were significantly more often affected with pseudomyxoma peritonei and had less preoperative chemotherapy. Multivariate analysis showed that a higher plasmatic level of Von Willebrand factor antigen at D0 (D0 VWF:Ag) was a protective predictive factor for HC (p = 0.049, HR: 0.97 CI 95% [0.94-1.00]). A D0 VWF:Ag level below 138% had a sensitivity of 87.5%, a specificity of 67% and an area under the curve of 80.3% (CI 95% [66.5-94], p < 0.01) for predicting HC. CONCLUSIONS: Through the identification of prognostic factors, this study highlighted a subgroup of patients with low risk of HC after HIPEC-ox. Based on these results, we propose a routine preoperative dosage of VWF that would help the surgeon to select the most suitable patients for HIPEC-ox.

Renal angiomyolipomas: At least two diseases. A series of patients treated at two European institutions.

OBJECTIVE: The aim of this study is to analyze the outcome of renal angiomyolipomas (AML) at two European institutions. METHODS: The data were collected from patients with a primary AML who were treated at Gustave Roussy, Villejuif, France and Fondazione IRCCS Istituto Nazionale dei Tumori in Milan, Italy from 1998 to 2014. The specimens were classified as classic AML (C AML) or epithelioid AML (E AML) based on the percentage of epithelioid cells. RESULTS: There were 40 patients identified for the study (35 C AML, 5 E AML). One patient had an associated tuberous sclerosis complex. Six patients (15%) had bilateral AML. The imaging results were significantly different between C/E AML. E AML was associated with fewer bilateral lesions, more renal vein/vena cava extension, and more poor or non-fatty aspects. Surgery/active surveillance (AS)/chemo radiation were applied for 28/11/1 patients, respectively. The median tumor size was significantly smaller (3.75 cm) in patients receiving AS (median 15 cm when surgically resected). The median patient follow-up was 43 months. The three-year overall survival was significantly better for patients with C AML than E AML (100% versus 50%, p < 0.0001). The univariate analysis identified the OS prognostic factors were E AML histologic subtype (p < 0.001), poor/non fatty features (p = 0.002), and renal vein extension on imaging (p = 0.01). CONCLUSION: AML manifests as at least two different entities with significantly different outcomes. Epithelioid subtype, poor/non-fatty features, and renal vein involvement are all associated with worse survival.

Long-term survival after aggressive treatment of relapsed serosal or distant pseudomyxoma peritonei.

INTRODUCTION: Complete cytoreductive surgery (CCRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have dramatically changed the prognosis of patients with pseudomyxoma peritonei (PMP). However, recurrences can still occur and no consensus has been reached regarding their optimal treatments. This study aimed to analyze the patterns of recurrence after CCRS plus HIPEC for PMP and potential subsequent treatments of these lesions. PATIENTS AND METHODS: Between 1992 and 2014, patients who had relapsed after treatment of PMP were selected from a prospective database of 251 patients who had undergone CCRS plus HIPEC with a curative intent. RESULTS: After a median follow-up of 85 months, 66 patients (26%) had relapsed with a median free interval of 25 months. The first recurrence was mostly located in the peritoneum, isolated in 50 patients (76%) and associated with extraperitoneal disease in 6 patients. Curatively intended treatment of the relapse, combining surgery and chemotherapy was achievable in 76% of the patients, leading to a 5-year overall survival (OS) rate of 83% from the date of treatment of the first recurrence. In contrast, the 5-year OS rate was only 27% (p < 0.001) for patients treated with non-curative therapy. An isolated peritoneal recurrence was predictive of greater amenability to curative therapy and a better prognosis. CONCLUSION: After CCRS plus HIPEC, serosal recurrences were more common than their distant counterparts. Distant relapses' emergence has raised the question of their optimal treatments. Very long-term survival can be obtained after further treatment of recurrent PMP for patients with limited disease and good general status.

Outcomes of hypnosis combined with local anesthesia during inguinal repair: a pilot study.

PURPOSE: To evaluate the usefulness and outcomes of hypnosis associated with local anesthesia during inguinal hernia repair procedure, notably on post-operative pain. METHODS: A prospective study included patients operated on inguinal hernia repair according to Lichtenstein technique from January 2013 to September 2014. The cohort was divided into three groups (group 1: local anesthesia; group 2: hypnosis and local anesthesia; and group 3: general anesthesia). A questionnaire was filled by each participant before and after surgery. Pre-operative apprehension, pain at hospital discharge, surgeon comfort during procedure, immediate satisfaction after hospital discharge, and satisfaction at 1 month after surgery were evaluated. RESULTS: A total of 103 patients were included in this study (group 1: n = 55; group 2: n = 35; and group 3: n = 13). Pre-operative apprehension and pain at hospital discharge's scores were significantly higher in the group 3 than in the groups 1 and 2 (p < 0.001). Pain at hospital discharge was significantly lower in the group 2 than in the group 1 (p = 0.03). Pre-operative apprehension, surgeon comfort during procedure, immediate satisfaction after hospital discharge, and satisfaction at 1 month after surgery were similar between groups 1 and 2. CONCLUSION: Hypnosis combined with local anesthesia is a feasible technique which allows extending inguinal hernia repair to a large population. There is no complication associated with its use.

Comparative study between biologic porcine dermal meshes: risk factors of postoperative morbidity and recurrence.

OBJECTIVE: Different types of biologic mesh have been introduced as an alternative to synthetic mesh for use in repairing contaminated ventral hernias because of their biocompatible nature. The aim of this study was to compare the clinical outcomes of patients who underwent complex ventral hernia repairs with either non cross-linked or cross-linked porcine dermal meshes. METHOD: This was retrospective analysis from a prospectively maintained database from January 2010 to May 2013. Patients undergoing open incisional hernia repair with a biologic mesh in the presence of a clean-contaminated, contaminated or dirty wound were reviewed. RESULTS: There were 39 patients who underwent single-staged abdominal wall reconstruction for a contaminated ventral hernia with a biologic mesh. In 15 cases, non cross-linked mesh was used (Strattice, n=8; Protexa, n=1; XenMatrix, n=6); a cross-linked mesh was used in the remaining 24 cases (Permacol n=21; CollaMend n=3). The median follow-up was 11.9 ± 10.6 months. The overall morbidity was 71.8% (n=28), with 15.4% (n=6) for grade I, 23.1% (n=9) for grade II, 23.1% (n=9) for grade III (n=3 grade IIIA, n=6 grade IIIB), 7.7% (n=3) for grade IV and 2.6% (n=1) for grade V. In the cross-linked group, there were six complications directly linked to the biologic mesh, compared with three in the non-cross-linked group. Overall wound morbidity was 41.0% (n=16). There were 13 hernia recurrences (33.3%), and recurrence rate was not significantly different for both groups. CONCLUSION: Despite the high rate of wound morbidity associated with the single-staged reconstruction of contaminated fields, it can be safely performed with biologic mesh reinforcement. Recurrence rate was not significantly different between cross-linked and non cross-linked porcine meshes.

Huge pseudomyxoma peritonei: Surgical strategies and procedures to employ to optimize the rate of complete cytoreductive surgery.

BACKGROUND: Complete cytoreductive surgery (CCRS) plus Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is the best-known treatment for pseudomyxoma peritonei (PMP). In 30% of the cases, PMP realize a widespread involvement of the peritoneal cavity. In these extreme situations, we developed, devoted strategies to optimize the feasibility and safety of CCRS. This study describes the surgical resections required for CCRS and the consequent approaches that we propose to achieve CCRS. MATERIALS AND METHODS: We defined "huge PMP" by a peritoneal cancer index (PCI) ≥ 28. Surgical procedures of patients operated on between 1994 and 2014 were retrospectively reviewed from a prospective database in a single institution. RESULTS: During this period, 311 patients were operated on and 247 (79%) underwent CCRS + HIPEC. Among them, 100 patients presented "huge" PMP and 54 patients underwent CCRS + HIPEC. In patients with "huge" PMP, the rate of CCRS + HIPEC was 25% before 2002 and reached 71% between 2011 and 2014. We identified 3 conditions for CCRS 1) to guaranty a sufficient length of residual small bowel 2) to preserve the left gastric vessels in order to preserve the superior third of the stomach 3) to ensure that the hepatic pedicle can be entirely cleared from its tumor involvement. None of the other peritonectomy procedures were decisional for CCRS. CONCLUSION: Our learning curve improved the selection and completion rate of CCRS + HIPEC for "huge PMP". Some anatomical and physiological prerequisites guarantee the feasibility and safety of such extensive surgeries.