Elective surgery for tumours of the splenic flexure: a French inter-group (AFC, SFCD, FRENCH, GRECCAR) survey.

BACKGROUND: In an elective setting, there is no consensus regarding the type of colectomy that is best for patients with tumors of the splenic flexure: segmental left colectomy (or splenic flexure colectomy), left hemicolectomy or subtotal colectomy (or extended right hemicolectomy). In the United Kingdom, extended right hemicolectomy is preferred by surgeons. The aim of the present survey was to report on the practices in France for this particular tumor location. METHODS: Between 15/07/17 and 15/10/17, members of two French surgical societies [the French Association of Surgery (AFC) and the French Society of Digestive Surgery (SFCD)] and two French surgical cooperative groups [the French Federation of Surgical Research (FRENCH) and the French Research Group of Rectal Cancer Surgery (GRECCAR)] were solicited by email to answer an online anonymous questionnaire. RESULTS: A total of 190 out of 420 surgeons participated in this study (response rate 45%). The preferred procedure was splenic flexure colectomy (70%), followed by left hemicolectomy (17%) and subtotal colectomy (13%). The most used surgical approach was laparoscopy (63%), followed by laparotomy (31%) and hand-assisted laparoscopy (6%). Lymph node dissection was extended to the middle colic artery in 29% of splenic flexure colectomies and in 33% of left hemicolectomies. Twenty-nine percent of responders thought that tumors of the splenic flexure had a worse prognosis in comparison with other colonic sites, because of insufficient lymph node dissection (73%) or a more advanced stage (50%) at diagnosis. However, this opinion did not change the type of colectomy performed. CONCLUSIONS: There is a strong consensus in France to operate tumors of the splenic flexure with a splenic flexure colectomy and lymph node dissection limited to the left colic artery.

Perioperative antibiotherapy should replace prophylactic antibiotics in patients undergoing pancreaticoduodenectomy preceded by preoperative biliary drainage.

BACKGROUND AND OBJECTIVES: Pancreaticoduodenectomy (PD) remains a morbid surgery. Preoperative biliary drainage (PBD) is often necessary before surgery but is associated with biliary contamination. We compared the postoperative complications of patients undergoing PBD who received the usual prophylactic antibiotics (PAs) or systematic antibiotherapy (ABT). METHODS: All patients who underwent surgery between 2008 and 2017 were included. Systematic perioperative ABT with piperacillin + tazobactam (ABT group) was implemented in 2014 as the standard of care for PBD. Patients treated in the period before such implementation, during which standard cefazolin was given, served as the controls (PAs group). The primary outcomes were postoperative complications. RESULTS: We included 122 patients with PBD who underwent surgery. There were no demographic differences between the two groups. Perioperative ABT was associated with a reduction in deep abdominal abscesses (36% vs 10%, P = .0008), respiratory tract infections (15% vs 3%; P = .02), bacteremia (41% vs 6%; P < .0001), and a shorter length of hospital stay (17 [13-27] vs 13 [10-14] days; P < .0001). ABT was a protective factor against the development of deep abdominal abscesses (odds ratio [OR] = 0.16; P = .001) whereas smoking (OR = 3.9) and pancreatic fistula (OR = 19.1) were risk factors. CONCLUSION: Systematic perioperative ABT in patients undergoing PD preceded by PBD may reduce deep surgical infections and the length of hospital stay.

Multicentre study of neoadjuvant chemotherapy for stage I and II oesophageal cancer.

BACKGROUND: The benefit of neoadjuvant chemotherapy (NCT) for early-stage oesophageal cancer is unknown. The aim of this study was to assess whether NCT improves the outcome of patients with stage I or II disease. METHODS: Data were collected from 30 European centres from 2000 to 2010. Patients who received NCT for stage I or II oesophageal cancer were compared with patients who underwent primary surgery with regard to postoperative morbidity, mortality, and overall and disease-free survival. Propensity score matching was used to adjust for differences in baseline characteristics. RESULTS: Of 1173 patients recruited (181 NCT, 992 primary surgery), 651 (55·5 per cent) had clinical stage I disease and 522 (44·5 per cent) had stage II disease. Comparisons of the NCT and primary surgery groups in the matched population (181 patients in each group) revealed in-hospital mortality rates of 4·4 and 5·5 per cent respectively (P = 0·660), R0 resection rates of 91·7 and 86·7 per cent (P = 0·338), 5-year overall survival rates of 47·7 and 38·6 per cent (hazard ratio (HR) 0·68, 95 per cent c.i. 0·49 to 0·93; P = 0·016), and 5-year disease-free survival rates of 44·9 and 36·1 per cent (HR 0·68, 0·50 to 0·93; P = 0·017). CONCLUSION: NCT was associated with better overall and disease-free survival in patients with stage I or II oesophageal cancer, without increasing postoperative morbidity.

Laparoscopic enucleation of pancreatic neoplasm.

BACKGROUND: Enucleation is an alternative procedure for treating benign and borderline neoplasms of the pancreas, which preserves healthy parenchyma and pancreatic function. This study aimed to evaluate the postoperative and long-term results after laparoscopic enucleation. METHODS: Data collected prospectively from 23 consecutive patients who underwent laparoscopic pancreatic enucleation were analyzed. RESULTS: Laparoscopic enucleation was achieved successfully for 21 patients (91.3%). One death (4%) occurred. A postoperative pancreatic fistula was observed in three cases (13%), and was clinically significant in one case (4%). Enucleation was performed for endocrine neoplasm in 15 patients (65%) and for cystic neoplasm in eight patients (35%). All the patients had benign tumors at the final histopathologic diagnosis. During a median follow-up period of 53 months, no patient experienced tumor recurrence or new-onset exocrine or endocrine insufficiency. CONCLUSION: Laparoscopic enucleation is a safe and effective procedure for the radical treatment of benign and borderline pancreatic tumors. The laparoscopic approach seems to be associated with a decrease in operative time, hospital stay, and pancreatic fistula after enucleation. Laparoscopy should become the standard approach in the future for enucleation of presumed benign lesions.

Long-Term Effects of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy on Bone Mineral Density: a 4-Year Longitudinal Study.

INTRODUCTION: Bone mineral density (BMD) declines in the initial years after bariatric surgery, but long-term skeletal effects are unclear and comparisons between sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are rare. DESIGN AND METHODS: An observational longitudinal study of obese patients undergoing SG or RYGB was performed. Whole-body (WB) BMD, along with BMD of the total hip (TH), femoral neck (FN), and lumbar spine (LS), was measured by dual-energy X-ray absorptiometry (DXA) before surgery and yearly thereafter for 4 years. Calciotropic hormones were also measured. RESULTS: Forty-seven patients undergoing RYGB surgery and 28 patients undergoing SG were included. Four years after RYGB, BMD declined by 2.8 ± 5.8% in LS, 8.6 ± 5% in FN, 10.9 ± 6.3% in TH, and 4.2 ± 6.2% in WB, relative to baseline. For SG, BMD declined by 8.1 ± 5.5% in FN, 7.7 ± 6% in TH, 2.0 ± 7.2% in LS, and 2.5 ± 6.4% in WB after 4 years, relative to baseline. Vitamin D levels increased with supplementation in both groups. Whereas parathyroid hormone levels increased slightly in the RYGB group, they decreased modestly in the SG group (P < 0.05 in both groups). CONCLUSIONS: Bone loss after 4 years was comparable between the two procedures, although RYGB was associated with a slightly greater decrease at the TH than SG. Bone health should therefore be monitored after both RYGB and SG.

[Intragastric migration of adjustable gastroplasty bands]. / Migration intragastrique des anneaux de gastroplastie ajustable.

BACKGROUND: The incidence of morbid obesity is increasing in France; adjustable gastric banding has become the most common surgical treatment. PATIENTS: We report seven cases of patients who presented with gastric erosion as a complication of gastric banding; this occurred at a mean interval of 4 years following the initial bariatric procedure. RESULTS: In six cases, repair was performed laparoscopically; one case required conversion to an open laparotomy approach. There was no mortality but morbidity occurred in 57% of cases: pleural effusion (two) and wound abscess (two). CONCLUSION: Gastric erosion and migration of adjustable gastric rings can occur at a long interval after laparoscopic gastric banding. Long-term follow-up is necessary in all such patients.

Improvements in autobiographical memory in schizophrenia patients after a cognitive intervention: a preliminary study.

BACKGROUND: Schizophrenia is associated with a reduction in accessing specific autobiographical information. This is consistent with the abnormal development of personal identity that characterizes this mental disorder. Using a schizophrenic population, the present study evaluates the effect of a cognitive intervention on autobiographical memory and the capacity to project oneself in the future. SAMPLING AND METHOD: The intervention consisted of group sessions, during which participants were trained to recollect specific events reported in their diary. Furthermore, exercises to stimulate their thoughts about their personal identity were proposed. An autobiographical memory test was administrated before the intervention, after the intervention and at the 3-month follow-up. In addition, neuropsychological and affective assessments were conducted before and after treatments. Patients' performances were compared to those from the control group. RESULTS: The ability to recall specific events was improved by the cognitive intervention, and the benefits were preserved 3 months later. However, no neuropsychological or affective benefit was found. CONCLUSION: Despite positive results on specific memory, any significant benefits have yet to be extended to other clinical variables such as symptom reduction and neuropsychological/social functioning. Nevertheless, the results revealed that cognitive remediation therapy could be a useful additional intervention for autobiographical memory deficits in schizophrenia patients.

Management of failure after surgery for gastro-esophageal reflux disease.

Surgical treatment of gastro-esophageal reflux disease (ST-GERD) is well-codified and offers an alternative to long-term medical treatment with a better efficacy for short and long-term outcomes. However, failure of ST-GERD is observed in 2-20% of patients; management is challenging and not standardized. The aim of this study is to analyze the causes of failure and to provide a treatment algorithm. The clinical aspects of ST-GERD failure are variable including persistent reflux, dysphagia or permanent discomfort leading to an important degradation of the quality of life. A morphological and functional pre-therapeutic evaluation is necessary to: (i) determine whether the symptoms are due to recurrence of reflux or to an error in initial indication and (ii) to understand the cause of the failure. The most frequent causes of failure of ST-GERD include errors in the initial indication, which often only need medical treatment, and surgical technical errors, for which surgical redo surgery can be difficult. Multidisciplinary management is necessary in order to offer the best-adapted treatment.

[Laparoscopic treatment of para-esophageal hernias]. / Traitement laparoscopique des hernies hiatales par roulement.

AIM: This retrospective study aims at analyzing the functional results obtained in patients operated by laparoscopy for a para-esophageal hernia. PATIENTS AND METHODS: From 1994 to 2004, 38 patients underwent a laparoscopic procedure for a symptomatic para-esophageal hiatal hernia of at least 3/4 of the proximal stomach: 27 females and 11 males, mean age 65 years (extreme: 22-84). There was no case on emergency, 4 patients had have at least one episode of intrathoracic volvulus. The operation consisted in gastric reduction into the abdominal cavity, excision of the sac, suture of the crura reinforced with a mesh in 6 patients and the construction of a gastric wrap. A postoperative barium swallow was performed on POD 3 in order to confirm the anatomical result. RESULTS: Mean operating time was 157 minutes (75-480), no case was converted into laparotomy. Four postoperative complications were observed (morbidity 10.8%): one gastric perforation diagnosed on POD 1, 2 severe dysphagias linked to the wrap, and one atelectasia. There was no death in this series. Functional results were evaluated by the mean of a questionnaire in 33 patients who had a follow up more than 6 months. Thirty-three questionnaires have been sent, 3 patients were lost and one was dead. Among the 29 patients analyzed, 14 were very satisfied, 11 were satisfied and 3 were deceived by the operation. Best results are obtained in patients with GERD, dysphagia or postprandial cardiothoracic symptoms. CONCLUSION: These results compared to the published data allow us to discuss about indications of surgery, the necessity to removal the hernia sac, and the advantages to reinforce the crura by the mean of a non absorbable mesh.

24-hour pH-impedance monitoring on therapy to select patients with refractory reflux symptoms for antireflux surgery. A single center retrospective study.

BACKGROUND: Treatment of gastro-esophageal reflux refractory symptoms is challenging. This monocenter retrospective study assessed the value of preoperative pH-impedance monitoring 'on' therapy to predict functional outcome after laparoscopic fundoplication in patients with refractory reflux symptoms. METHODS: Patients with a preoperative pH-impedance monitoring 'on' proton pump inhibitors (PPIs) twice daily were assessed at least 6 months after a laparoscopic fundoplication for refractory reflux symptoms. Failure of fundoplication was defined by a Visick score > 2. Postoperative symptoms were assessed by the reflux disease questionnaire (RDQ). The pH-impedance parameters analyzed were the number of reflux events (total, acid, non-acid), esophageal acid exposure time, esophageal bolus exposure time, and symptom-reflux association defined by symptom index (SI) >50% and symptom association probability (SAP) >95%. KEY RESULTS: Thirty-three patients (18 female patients, median age 46 years) were assessed after a mean follow-up of 41.3 (range 7-102.2) months. Seven (21.2%) patients were considered as failures. Compared to patients with favorable outcome, these patients were more often 'on' PPI therapy (86% vs 23%, p < 0.05) and had higher RDQ scores in each domain: heartburn (p < 0.05), regurgitation (p < 0.05) and dyspepsia (p < 0.05). A positive SAP was the only pH-impedance parameter statistically associated with successful postoperative outcome (p = 0.004). CONCLUSIONS & INFERENCES: On therapy, a preoperative positive symptom association probability is the only pH-impedance parameter associated with favorable outcome after laparoscopic fundoplication for refractory reflux symptoms. These results should be confirmed by prospective studies.

All-trans retinoic acid targets gastric cancer stem cells and inhibits patient-derived gastric carcinoma tumor growth.

Gastric carcinoma is the third leading cause of cancer-related death worldwide. This cancer, most of the time metastatic, is essentially treated by surgery associated with conventional chemotherapy, and has a poor prognosis. The existence of cancer stem cells (CSC) expressing CD44 and a high aldehyde dehydrogenase (ALDH) activity has recently been demonstrated in gastric carcinoma and has opened new perspectives to develop targeted therapy. In this study, we evaluated the effects of all-trans-retinoic acid (ATRA) on CSCs in human gastric carcinoma. ATRA effects were evaluated on the proliferation and tumorigenic properties of gastric carcinoma cells from patient-derived tumors and cell lines in conventional 2D cultures, in 3D culture systems (tumorsphere assay) and in mouse xenograft models. ATRA inhibited both tumorspheres initiation and growth in vitro, which was associated with a cell-cycle arrest through the upregulation of cyclin-dependent kinase (CDK) inhibitors and the downregulation of cell-cycle progression activators. More importantly, ATRA downregulated the expression of the CSC markers CD44 and ALDH as well as stemness genes such as Klf4 and Sox2 and induced differentiation of tumorspheres. Finally, 2 weeks of daily ATRA treatment were sufficient to inhibit gastric tumor progression in vivo, which was associated with a decrease in CD44, ALDH1, Ki67 and PCNA expression in the remaining tumor cells. Administration of ATRA appears to be a potent strategy to efficiently inhibit tumor growth and more importantly to target gastric CSCs in both intestinal and diffuse types of gastric carcinoma.

Laparoscopic adjustable gastric banding results after 2 years with two different band types.

BACKGROUND: Laparoscopic gastric banding is the most common operation in Europe for morbid obesity. Many devices from different companies are now available. The aim of this study was to compare the results over a 2-year period of 2 types of band: the Lap-Band and the Minimizer band. METHODS: In a non-randomized study, 2 consecutive groups were prospectively analyzed. Group A consisted of 120 patients who received the Lap-Band, and group B consisted of 68 patients who received the Minimizer band which contains eyelets. All the bands were placed above the lesser sac by the perigastric approach. RESULTS: 4 early complications were observed in group A (1 phlebitis, 1 pneumopathy and 2 early displacements of the band); and 1 in group B (1 retention of urine). After a follow-up of 2 years, the displacement rate of the band was 10.8% in group A and 0% in group B. One gastric erosion was observed in group B, but not in group A. After 2 years, the average loss of excess weight was 50% in both groups. CONCLUSION: With the Minimizer band, we did not observe any slipping, and the efficacy with respect to weight loss was equivalent to the Lap-Band.

[Value of surgical ampullectomy in the management of benign ampullary tumors]. / Intérêt de l'ampullectomie chirurgicale dans la prise en charge des lésions bénignes de l'ampoule de Vater.

AIM OF THE STUDY: To report the results of transduodenal excision (TDE) for tumors of the ampulla of Vater. PATIENTS AND METHODS: From 1998 to 2003, 10 patients underwent a transduodenal excision for presumed benign tumors of the ampulla of Vater. After resection, frozen sections were performed to ensure negative margins. RESULTS: There was no operative mortality. A postoperative pancreatitis occurred in one patient. For nine patients the postoperative course was uneventful. The mean duration of hospital stay was 18 +/-11 days. The final pathology showed adenoma in 8 patients, an adenocarcinoma in one patient and inflammatory lesions in other one. With a mean follow-up of 20 months, endoscopy did not show any recurrence in patients with benign lesion. Patient with an invasive cancer developed recurrence. CONCLUSION: Transduodenal excision is safe and effective treatment for benign ampullary tumors. TDE should be the operation of choice for patients with histologically-proven benign ampulloma, staged as uT1 by endoscopic ultrasound. This approach could reduce the rate of pancreaticaduodenoctomy performed for benign ampullomas.

[Surgical management of obstructed colonic cancer]. / Prise en charge du cancer colique en occlusion.

INTRODUCTION: Management of obstructed colonic carcinomas is a surgical challenge because it happens more often in elderly patients. The aim of our study is to assess mortality and morbidity rates of procedures performed in emergency for this pathology. PATIENTS AND METHOD: Between January 1st, 1998 and December 31st 2003, 22 patients underwent an emergency procedure for obstructive colonic obstruction due to an adenocarcinoma. Obstruction was defined as an emesis, distension on examination, no gas or stool since 24 hours and confirmatory plain radiograph film. RESULTS: Twenty patients (91%) underwent surgical procedure and two others received a colonic stent. Eleven patients (50%) underwent left colonic resection and intraoperative colonic cleansing was undertaken in 3 of these patients. One patient underwent a lateral colostomy, three patients (14%) underwent a right colectomy. A Hartmann's procedure was performed in six cases (27%). Morbidity occurred in 23% (50% were from anastomotic complication). Mortality rate was 27% (44% if aged more than 75 years old) (one superior mesenteric ischemia, and five heart and respiratory failures). Two-year survival rate was 61% and five year survival rate was 47%. Median survival was 24 months. CONCLUSION: Our study confirms that obstructed colonic cancer has a bad prognosis because it happens in elderly and not healthy patients. Priority must be given to the restoration of colonic permeability.

In vitro studies of elastin-fibrin biomaterial degradation: preservative effects of protease inhibitors and antibiotics.

The degradability of a new elastin-fibrin material was tested in vitro versus human pancreatic elastase (HPE) and plasmin (PL) activities. It is shown that aprotinine Iniprol, a well-known protease inhibitor and Eglin C, a new potent inhibitor of HPE, especially when used in synergy, efficiently protected the material. A small amount of specific antibiotics was incorporated into the material. The two products will allow the material to be used in digestive surgery with improved safety.

Conversions and complications of laparoscopic treatment of gastroesophageal reflux disease. Formation for the Development of Laparoscopic Surgery for Gastroesophageal Reflux Disease Group.

BACKGROUND: It is now known that laparoscopic surgery is associated with less discomfort and less pain during the patient's postoperative course. Laparoscopic treatment of gastroesophageal reflux disease (GERD) is technically feasible. The advantages of this minimally invasive surgical route seem well adapted to a basically functional surgery. However, it is important to know whether laparoscopic access adds a specific risk to this type of surgery. PATIENTS AND METHODS: A retrospective survey was conducted among members of the Formation for the Development of Laparoscopic Surgery (FDCL) group during 1993. A form was filled in anonymously for each patient who had had either a conversion or a postoperative complication following a laparoscopic procedure for GERD. Items concerned preoperative workup, technical details of surgery, and postoperative course. Another form was used to ascertain how many surgical procedures for GERD had been performed during the same period, either laparoscopically or via an elective laparotomy. Nineteen surgeons from the FDCL group took part in the study. From 1991 to 1993, 758 patients underwent a laparoscopic procedure for GERD, while during the same period 38 patients underwent an elective laparotomy. RESULTS: In the laparoscopic group, there were 294 Nissen, 334 Nissen-Rossetti, and 106 Toupet procedures, and 24 Angelchik prosthesis placements. No deaths occurred. The operation had to be converted to an open procedure in 32 cases (4.2% conversion rate). In 7 cases the conversion was due to an intraoperative complication, whereas in 25 cases the conversion was done because of technical difficulties. In 6 cases an intraoperative complication was treated laparoscopically without conversion. Thirty post-operative complications were recorded (morbidity 4%), leading to a reoperation in 12 cases. Five major complications were observed: 2 esophageal perforations, 2 gastric perforations, and 1 bowel perforation. CONCLUSION: These results compare favorably with those of open surgery and suggest that laparoscopic treatment of GERD is as safe as open surgery when performed by a surgeon experienced in laparoscopy.

Laparoscopic cholecystectomy using intracorporeal lithotripsy.

Over a 13-month period (November 1988 to December 1989), we performed our first 104 laparoscopic cholecystectomies using an intracorporeal ultrasonic lithotripsy technique. The procedure in three of these patients was converted to an open operation because of hemorrhage with unexpected findings of cirrhosis in two patients and dense subhepatic adhesions in a third. Endoscopic retrograde cholangiopancreatography was successfully used in three other patients in whom common bile duct stones were identified. We encountered only three postoperative complications out of all the laparoscopic cholecystectomies performed. One complication was a biliary fistula that closed spontaneously 1 week after surgery. The remaining complications were attributable to abscesses, one subhepatic and one pelvic, which were aspirated and drained laparoscopically. There were no deaths. Advantages of the laparoscopic approach included decreased perioperative pain, shortened hospitalization, absence of scar, and more rapid return to prehospitalization activities.

Interruption of professional and home activity after laparoscopic cholecystectomy among French and American patients.

With a laparoscopic approach, patients can undergo cholecystectomy with a shorter hospitalization, minimal pain, and quicker recovery. It has not been demonstrated, however, that patients actually return to work after laparoscopic cholecystectomy faster than the traditional 4- to 6-week absence from work after a standard open procedure. A survey of 104 French and 84 American patients undergoing laparoscopic cholecystectomy revealed that postoperative discomfort was completely resolved in 2 weeks in 73% of French and 93% of American patients. All but 11 French and 5 American patients were back to normal home activities by 2 weeks after the operation. Of the 35 American and 40 French patients who had professional activity outside the home, 63% and 25%, respectively, returned to work within 14 days. Five (14%) of the American patients and 12 (30%) of the French patients returned to work 4 weeks or more after the operation. The amount of physical activity on the job correlated with the period off work, but, interestingly, at least six patients with very hard physical activity at work (including construction workers) were able to return to full work activity within 1 week. These data suggest that early return to work is possible and that pain resolves quickly after laparoscopic cholecystectomy. The economic benefit of having patients back on the job quickly, however, may be less than expected until cultural norms change with regard to leave of absence after major surgery.