Real-world implementation of a geriatric-specific ERAS protocol in patients undergoing colonic cancer surgery.

BACKGROUND: The aim of this single-center observational study was to evaluate the impact of implementing Enhanced Recovery After Surgery (ERAS) protocols, combined with systematic geriatric assessment and support, on surgical and oncological outcomes in patients aged 70 or older undergoing colonic cancer surgery. METHODS: Two groups were formed from an actively maintained database from all patients undergoing laparoscopic colonic surgery for neoplasms during a defined period before (standard group) or after (ERAS group) the introduction of an ERAS program associated with systematic geriatric assessment. The primary outcome was postoperative 90-day morbidity. Secondary outcomes were total length of hospital stay, initiated and completed adjuvant chemotherapy (AC) rate, and 1-year mortality rate. RESULTS: A total of 266 patients (135 standard and 131 ERAS) were included in the study. Overall 90-day morbidity and mean hospital stay were significantly lower in the ERAS group than in the standard group (22.1% vs. 35.6%, p = 0.02; and 6.2 vs. 9.3 days, p < 0.01, respectively). There were no differences in readmission rates and anastomotic complications. AC was recommended in 114 patients. The rate of initiated treatment was comparable between the groups (66.6% vs. 77.7%, p = 0.69). The rate of completed AC was significantly higher in the ERAS group (50% vs. 20%, p < 0.01) with a lower toxicity rate (57.1% vs. 87.5%, p = 0.002). The 1-year mortality rate was higher in the standard group (7.4% vs. 0.8%, p < 0.01). CONCLUSIONS: The combination of ERAS protocols and geriatric assessment and support reduces the overall morbidity rate and improves 12-month oncologic outcomes.

Perioperative FOLFOX 4 Versus FOLFOX 4 Plus Cetuximab Versus Immediate Surgery for High-Risk Stage II and III Colon Cancers: A Phase II Multicenter Randomized Controlled Trial (PRODIGE 22).

BACKGROUND: Perioperative chemotherapy has proven valuable in several tumors, but not in colon cancer (CC). OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of perioperative chemotherapy in patients with locally advanced nonmetastatic CC. METHODS: This is a French multicenter randomized phase II trial in patients with resectable high-risk T3, T4, and/or N2 CC on baseline computed tomography (CT) scan. Patients were randomized to receive either 6 months of adjuvant FOLFOX after colectomy (control) or perioperative FOLFOX for 4 cycles before surgery and 8 cycles after (FOLFOX peri-op). In RAS wild-type patients, a third arm testing perioperative FOLFOX-cetuximab was added. Tumor Regression Grade (TRG1) of Ryan et al was the primary endpoint. Secondary endpoints were toxicity, perioperative morbidity, and quality of surgery. RESULTS: A total of 120 patients were enrolled. At interim analysis, the FOLFOX-cetuximab arm was stopped (lack of efficacy). The remaining 104 patients (control, n = 52; FOLFOX preop n = 52) represented our intention-to-treat population. In the FOLFOX perioperative group, 96% received the scheduled 4 cycles before surgery. R0 resection and complete mesocolic excision rate were 94% and 93%, respectively. Overall mortality and morbidity rates were similar in both groups. Perioperative FOLFOX chemotherapy did not improve major pathological response rate (TRG1 = 8%) but was associated with a significant pathological regression (TRG1-2 = 44% vs 8%, P < 0.001) and a trend to tumor downstaging as compared to the control group. CT scan criteria were associated with a 33% rate of overstaging in control group. CONCLUSIONS: Perioperative FOLFOX for locally advanced resectable CC is feasible with an acceptable tolerability but is not associated with an increased major pathological response rate as expected. However, perioperative FOLFOX induces pathological regression and downstaging. Better preoperative staging tools are needed to decrease the risk of overtreating patients.

Management of rectal cancer: the 2016 French guidelines.

AIM: Rectal cancer is a malignant disease requiring multidisciplinary management. In view of the increasing number of studies published over the past decade, a comprehensive update is required to draw recommendations for clinical practice mandated by the French Research Group of Rectal Cancer Surgery and the French National Coloproctology Society. METHOD: Seven questions summarizing the treatment of rectal cancer were selected. A search for evidence in the literature from January 2004 to December 2015 was performed. A drafting committee and a large group of expert reviewers contributed to validate the statements. RESULTS: Recommendations include the indications for neoadjuvant therapy, the quality criteria for surgical resection, the management of postoperative disordered function, the role of local excision in early rectal cancer, the place of conservative strategies after neoadjuvant treatment, the management of synchronous liver metastases and the indications for adjuvant therapy. A level of evidence was assigned to each statement. CONCLUSION: The current clinical practice guidelines are useful for the treatment of rectal cancer. Some statements require a higher level of evidence due to a lack of studies.

Combined NOTES total mesorectal excision and single-incision laparoscopy principles for conservative proctectomy: a single-centre study.

BACKGROUND: Surgery for low rectal cancer remains a challenge when a standard laparoscopic approach is used. Transanal endoscopic total mesorectal excision (TME) has been shown to be feasible and to be associated with a low conversion rate. Combining the transanal and transabdominal single-port approaches (with an abdominal single port implanted in the future stoma and extraction site) could allow TME with minimal wound trauma, low morbidity, and faster recovery. The aim of the current study was to assess the short- and mid-term results of this technique. METHODS: We conducted a prospective single-centre study of consecutive patients presenting with low rectal cancer requiring a conservative proctectomy with a manual coloanal anastomosis between January 2012 and April 2015. RESULTS: During the study period, 41 patients were recruited. Conversion to open surgery was required in only one patient (2.4%). The median operating time was 358.5 min (range 300-600 min). Partial intersphincteric resection was necessary for 15 patients (36.6%). The specimens were mostly extracted via the abdominal access (n = 34) without wound complications. The mean number of lymph nodes harvested was 12.7 (range 6-24 lymph nodes). Specimens were graded as complete (n = 31) or nearly complete (n = 10) in all of the patients, and the circumferential resection margin positivity was 4.9%. Intraoperative morbidity rate was 4.9%, and the 30-day morbidity rate was 24.4% (n = 10). Sixty per cent (n = 6) of the patients with 30-day morbidity were Dindo I-II. At a median follow-up of 29 months, overall and disease-free survival rates were 97.5 and 80.5%, respectively. The stoma-free survival rate was 95.1%. CONCLUSIONS: Combining an endoscopic transanal TME and a single laparoscopic ileostomy-site proctectomy is a promising minimally invasive approach for the treatment of low rectal cancer.

Diffuse malignant peritoneal mesothelioma: Evaluation of systemic chemotherapy with comprehensive treatment through the RENAPE Database: Multi-Institutional Retrospective Study.

PURPOSE: Diffuse malignant peritoneal mesothelioma (DMPM) is a severe disease with mainly locoregional evolution. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the reported treatment with the longest survival. The aim of this study was to evaluate the impact of perioperative systemic chemotherapy strategies on survival and postoperative outcomes in patients with DMPM treated with curative intent with CRS-HIPEC, using a multi-institutional database: the French RENAPE network. PATIENTS AND METHODS: From 1991 to 2014, 126 DMPM patients underwent CRS-HIPEC at 20 tertiary centres. The population was divided into four groups according to perioperative treatment: only neoadjuvant chemotherapy (NA), only adjuvant chemotherapy (ADJ), perioperative chemotherapy (PO) and no chemotherapy before or after CRS-HIPEC (NoC). RESULTS: All groups (NA: n = 42; ADJ: n = 16; PO: n = 16; NoC: n = 48) were comparable regarding clinicopathological data and main DMPM prognostic factors. After a median follow-up of 61 months, the 5-year overall survival (OS) was 40%, 67%, 62% and 56% in NA, ADJ, PO and NoC groups, respectively (P = 0.049). Major complications occurred for 41%, 45%, 35% and 41% of patients from NA, ADJ, PO and NoC groups, respectively (P = 0.299). In multivariate analysis, NA was independently associated with worse OS (hazard ratio, 2.30; 95% confidence interval, 1.07-4.94; P = 0.033). CONCLUSION: This retrospective study suggests that adjuvant chemotherapy may delay recurrence and improve survival and that NA may impact negatively the survival for patients with DMPM who underwent CRS-HIPEC with curative intent. Upfront CRS and HIPEC should be considered when achievable, waiting for stronger level of scientific evidence.

Professional risks when carrying out cytoreductive surgery for peritoneal malignancy with hyperthermic intraperitoneal chemotherapy (HIPEC): A French multicentric survey.

BACKGROUND: Over the last two decades, many surgical teams have developed programs to treat peritoneal carcinomatosis with extensive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Currently, there are no specific recommendations for HIPEC procedures concerning environmental contamination risk management, personal protective equipment (PPE), or occupational health supervision. METHODS: A survey of the institutional practices among all French teams currently performing HIPEC procedures was carried out via the French network for the treatment of rare peritoneal malignancies (RENAPE). RESULTS: Thirty three surgical teams responded, 14 (42.4%) which reported more than 10 years of HIPEC experience. Some practices were widespread, such as using HIPEC machine approved by the European Community (100%), individualized or centralized smoke evacuation (81.8%), "open" abdominal coverage during perfusion (75.8%), and maintaining the same surgeon throughout the procedure (69.7%). Others were more heterogeneous, including laminar flow air circulation (54.5%) and the provision of safety protocols in the event of perfusate spills (51.5%). The use of specialized personal protective equipment is ubiquitous (93.9%) but widely variable between programs. CONCLUSION: Protocols regarding cytoreductive surgery/HIPEC and the associated professional risks in France lack standardization and should be established.

A distinctive epitheliomesenchymal biphasic tumor in the duodenum: the first case of duodenoblastoma?

Epitheliomesenchymal biphasic neoplasms are extremely rare in the duodenum, and most of these are carcinosarcomas. Miettinen et al. (Am J Surg Pathol 33:1370-7, 2009) recently reported three cases of a novel distinctive epitheliomesenchymal biphasic tumor of the stomach in young adults. In view of the resemblance to other childhood blastomas, they proposed to refer to this entity as a gastroblastoma. Since none of the components were sufficiently atypical, the gastroblastoma seemed more comparable to this kind of tumor than carcinosarcomas or other aggressive and malignant biphasic tumors. This report describes a duodenal location of a similar epitheliomesenchymal biphasic tumor in a 22-year-old woman. To our knowledge, this is the first reported case occurring primarily in the duodenum and might be the first case of "duodenoblastoma."

[Predictive factors of tumour response after neoadjuvant chemoradiation for locally advanced rectal cancer and correlation of these factors with survival]. / Facteurs prédictifs de réponse à la radiochimiothérapie néoaduvante dans les cancers rectaux localement évolués et corrélation de ces facteurs avec la survie.

PURPOSE: Neoadjuvant chemoradiation followed by surgery is the standard of care for locally advanced rectal cancer. The aim of this study was to correlate tumour response to survival and to identify predictive factors for tumour response after chemoradiation. PATIENTS AND METHODS: From 1998 to 2008, 168 patients with histologically-proven locally advanced adenocarcinoma treated by preoperative chemoradiation before total mesorectal excision were retrospectively studied. They received a radiation dose of 45 Gy with a concomitant 5-fluoro-uracil-based chemotherapy. Analysis of tumour response was based on the lowering of T stage between pre-treatment endorectal ultrasound and pathologic specimens. Overall and progression-free survival was correlated with tumour response. Tumour response was analysed with predictive factors. RESULTS: The median follow-up was 34 months. Five-year disease-free survival and overall survival were respectively of 44.4% and 74.5% in the whole population, 83.4% and 83.4% in patients with pathological complete response, 38.6% and 71.9% in patients with tumour downstaging, 29.1% and 58.9% in patients with absence of response. A pre-treatment concentration of carcinoembryonnic antigen below 5 ng/mL was significantly associated with tumour downstaging and significantly independently associated with pathologic complete tumour response (P = 0.019). CONCLUSION: Downstaging and complete response after chemoradiation improved progression-free survival and overall survival of locally advanced rectal adenocarcinoma. In multivariate analysis, a pre-treatment concentration of carcinoembryonnic antigen below 5 ng/mL was associated with complete tumour response, hence with tumour downstaging.

Is neoadjuvant chemotherapy prior to radio-chemotherapy beneficial in T4 anal carcinoma?

BACKGROUND: This study retrospectively describes the outcome of a series of 38 patients (pts) with T4 anal carcinoma exclusively treated by radio and chemotherapy. PATIENTS AND METHODS: From 1992 to 2007, 38 pts with UST4-N0-2-M0 anal carcinoma were treated with exclusive radiotherapy and chemotherapy. All patients received external beam radiotherapy (EBRT) (median dose 45 Gy) with a concomitant chemotherapy (5-fluorouracil-cisplatin). Eleven patients received neo-adjuvant chemotherapy (5-fluorouracil-cisplatin). After 2-8 weeks, a 15-20 Gy boost was delivered either with EBRT (20 pts) or interstitial (192)Ir brachytherapy (18 pts). Mean follow-up was 66 months. RESULTS: After chemoradiation therapy (CRT), 13 pts (34%) had a complete response, 23 pts (60%) a response >50% (2 pts were not evaluated). The 5-year-disease-free survival was 79.2 ± 6.5%, and the 5-year overall survival was 83.9 ± 6%. Eight patients developed tumor progression (mean delay 8.8 months), six of them requiring a salvage surgery with definitive colostomy for local relapse. Late severe complication requiring colostomy was observed in 2 pts. The 5-year-colostomy-free survival was 78 ± 6.9%. Patients who received primary chemotherapy had a statistically significant better 5-year colostomy-free survival (100% vs. 38 ± 16.4%, P = 0.0006). CONCLUSION: T4 anal carcinoma can be treated with a curative intent using a sphincter-sparing approach of CRT, and neo-adjuvant chemotherapy should be considered prior to radiotherapy.

[Colonic interposition for esophageal replacement after caustic ingestion]. / Reconstruction oesophagienne pour séquelles de brûlure caustique: coloplasties, mode d'emploi.

Retrosternal coloplasty is the gold standard for esophageal reconstruction after caustic injury of the digestive tract. Complete preoperative otolaryngology evaluation and the control of the psychiatric disease are key factors for success. In the absence of controlled studies, the choice between the right and the left colon graft relies on the anatomy of the blood supply to the colon and on the individual surgeon's preference. Treatment of associated pharyngeal and laryngeal injuries is mandatory at the time of esophageal reconstruction. In experienced hands mortality rates are less than 5% but specific postoperative complications (graft necrosis, leakage, anastomotic stricture) are high. The low risk of cancer development in the by-passed esophagus does not justify routine esophagectomy at the time of reconstruction. Sixty to eighty percent of patients would finally retrieve nutritional autonomy after coloplasty for caustic injury. Late acquired dysfunctions of the coloplasty (anastomotic strictures, graft redundancy) requiring revision surgery occur frequently and might jeopardize an already fragile functional result. Timely diagnosis and treatment of such complications and the necessity of continuous psychological surveillance justify the need for long term follow up in these patients.

Presentation and prognosis of local recurrence after total mesorectal excision.

OBJECTIVE: The aim of this study was to describe the presentation, treatment and prognosis of local recurrences following total mesorectal excision for rectal adenocarcinoma. METHOD: Between 1999 and 2002, 201 patients were treated with total mesorectal excision for mid or low rectal cancer and were followed up prospectively. RESULTS: Overall 2-year survival was 85%. The 2-year recurrence rate was 8%. Eighteen patients developed local recurrence at 3-60 months. Nine recurrences originated from the pelvic sidewall. These recurrences were symptomatic in 90% of patients. Only two patients were reoperated with a R0 resection and were alive without local recurrence after 19 and 31 months. The seven others died within 9 months. Nine recurrences originated from an anastomotic suture line. Only two had symptoms. A R0 surgical resection was performed in all patients with a 67% sphincter conservation rate. After 26-months of median follow-up (range 7-58), all patients were alive. CONCLUSION: Half of the local recurrence after total mesorectal excision was located at the anastomotic site. Rectoscopic examination should be performed regularly to detect these anatomotic recurrences that are accessible to a R0 itérative resection.

[Extensive digestive caustic burns: what are the limits for resection? A series of 12 patients]. / Brûlures digestives extensives par caustiques : Quelles limites à l'exérèse ?. A propos de 12 patients.

AIM OF THE STUDY: To report the results of oesogastric resections extended to surrounding organs following caustic ingestion, and to precise indications for resection and results of reconstruction. PATIENTS AND METHODS: From 1988 to 2001, 12 patients underwent oesophago-gastrectomy, extended to duodenum and pancreatic head (n = 6), jejunum (n = 4), colon (n = 2), spleen (n = 2) or pancreatic body (n = 1). Early morbidity and mortality, specificities of reconstruction, and quality of oral feeding were assessed retrospectively. RESULTS: Mean intensive care unit stay was 50 days (range: 16-152 days). All patients developed complications. Six patients were reoperated for secondary extension of caustic burns, mainly to colon (n = 4), small bowel (n = 2) and pancreas (n = 2). Three patients died on postoperative days 17, 20, and 130. Secondarily, eight patients (75%) underwent a substernal right ileocoloplasty. Six patients (50%) survived initial resection, and esophageal reconstruction. After a mean follow-up of 35 months (range: 7-87 months), four patients (33%) eat normally. CONCLUSIONS: After caustic burn, oesogastric resections extended to surrounding organs are associated with high morbidity and mortality. However, return of normal oral feeding can be expected in 33% of cases. Secondary extension of caustic burns to adjacent organs is a common eventuality, and may lead to prompt reintervention. Massive injury to small bowel or colon may compromise digestive function or secondary esophageal reconstruction, and thus may be the reasonable limit for resection.

[Laparoscopic sigmoid resection for diverticulitis: is learning phase associated with increased morbidity?]. / Sigmoïdectomie laparoscopique pour diverticulite: la phase d'apprentissage est-elle associée à une sur-morbidité?

AIM: To assess retrospectively the results of laparoscopic sigmidectomy for diverticulitis, with intent to treat, in 58 consecutive patients operating by one surgeon compared with a control group operating by laparotomy. MATERIALS AND METHODS: From 1995 to 2001, 90 consecutive patients undergoing elective sigmoid resection for diverticulitis were divided into 3 groups: laparotomy (Group 1 : n = 32), first cases of laparoscopy (Group 2 : n = 29) and last cases of laparoscopy (Group 3 : n = 29). These 3 groups were similar according to age, sex, Body Mass Index (BMI), American society of anesthesia score (ASA), previous abdominal surgery, number of attacks of diverticulitis, and time between last attack and surgery. Following criteria were studied: operating time, conversation rate, intra-operative and post-operative morbidity, return of intestinal transit, and hospital stay. RESULTS: During laparoscopy, conversion was mandatory in 24% of the cases (7/29) in group 2 and 14% in group 3 (4/29; NS). No intra-operative morbidity was noted in the 58 laparoscopies. Mean operative time was 240 min in group 1, 259 min in group 2, and 241 min in group 3 (NS). Postoperative morbidity was observed in 31% of patients in group 1, 34% in group 2, and 10% in group 3 (p = 0.02). Returm of intestinal transit and oral ingestion and mean hospital stay were significantly shorter in group 2 and group 3 versus group 1 (p < 0.05). CONCLUSION: Our results confirm previous data demonstrating faisability of laparoscopic sigmodectomy for diverticulitis and its benefice in terms of return of intestinal transit and hospital stay. Furthermore, our study suggest that when surgeon gain experience, conversion rate, morbidity and operative time can be reduced.