Abstract Background Pancreatic fistula (PF) is one of the most common postoperative complications of pancreatoduodenectomy (PD). A recent International Study Group on Pancreatic Fistula (ISGPF) ...definition grades the severity of PF according to the clinical impact on the patient's hospital course. Although PF is generally treated conservatively (grade A), some cases may require interventional procedures (grade B) or may be life-threatening and necessitate emergency reoperation (grade C). The aim of the present study was to evaluate the incidence of postoperative grade C PF after PD and to assess the prognosis and risk factors for this life-threatening condition. Study design Between January 2000 and December 2006, 680 consecutive patients underwent PD in 5 digestive surgery departments in the northwest region of France (Lille, Amiens, Rouen, and Caen). PF was defined as drain output of any measurable volume of fluid on or after postoperative day 3 with amylase content greater than 3 times the serum amylase activity (ISGPF guidelines). To identify possible risk factors for grade C PF, we reviewed the records of 111 (16.3%) patients with postoperative PF and compared grade C cases with grade A+B cases. Results The median age was 59 years (range 22–87). The male-to-female ratio was 1.6:1. Fifty-six (50.4%) PDs were performed via pancreaticogastrostomy and 55 via pancreaticojejunostomy. Overall mortality was 2% (n = 14). Grade C PF was observed in 36 (32%) patients, of whom 17 (47%) had sepsis due to an abdominal collection, 16 (44%) had postoperative bleeding, 10 (27.7%) had bleeding associated with abdominal collection, and 3 (9%) had multi-organ failure due to other causes. Of these 36 patients, 35 (97%) underwent reoperation. The mortality rate in grade C PF patients was 38.8%. The major causes of death were sepsis (n = 6) and recurrent bleeding after reoperation (n = 5). Grade C PF increased the duration of postoperative hospitalization (46 vs 29 days, P < .001). Univariate analysis showed that peroperative soft pancreatic parenchyma, peroperative blood transfusion, and postoperative bleeding were significant risk factors for grade C PF, with P values of .011, .003, and .001, respectively. No risk factors for grade C PF were identified in a multivariate analysis. The sensibility, specificity, positive predictive value, and negative predictive value of the presence of the 3 risk factors for grade C PF were 13.89%, 100%, 100%, and 70.75%, respectively. Conclusion Sixteen percent of patients had PF after PD. Among them, 30% had grade C PF, with a mortality rate of about 40%. Achievement of a 100% predictive positive value for grade C PF after PD in individuals with 3 discriminant risk factors (peroperative soft pancreatic parenchyma, peroperative transfusion, and postoperative bleeding) is a first step towards the identification of high-risk patients who should be managed differently from other patients with PF during or after PD.
About 25% of patients with acute diverticulitis require emergency intervention. Currently, most patients with diverticular peritonitis undergo a Hartmann's procedure. Our objective was to assess ...whether primary anastomosis (PA) with a diverting stoma results in lower mortality rates than Hartmann's procedure (HP) in patients with diverticular peritonitis.
We conducted a multicenter randomized controlled trial conducted between June 2008 and May 2012: the DIVERTI (Primary vs Secondary Anastomosis for Hinchey Stage III-IV Diverticulitis) trial. Follow-up duration was up to 18 months. A random sample of 102 eligible participants with purulent or fecal diverticular peritonitis from tertiary care referral centers and associated centers in France were equally randomized to either a PA arm or to an HP arm. Data were analyzed on an intention-to-treat basis. The primary end point was mortality rate at 18 months. Secondary outcomes were postoperative complications, operative time, length of hospital stay, rate of definitive stoma, and morbidity.
All 102 patients enrolled were comparable for age (p = 0.4453), sex (p = 0.2347), Hinchey stage III vs IV (p = 0.2347), and Mannheim Peritonitis Index (p = 0.0606). Overall mortality did not differ significantly between HP (7.7%) and PA (4%) (p = 0.4233). Morbidity for both resection and stoma reversal operations were comparable (39% in the HP arm vs 44% in the PA arm; p = 0.4233). At 18 months, 96% of PA patients and 65% of HP patients had a stoma reversal (p = 0.0001).
Although mortality was similar in both arms, the rate of stoma reversal was significantly higher in the PA arm. This trial provides additional evidence in favor of PA with diverting ileostomy over HP in patients with diverticular peritonitis. ClinicalTrials.gov Identifier: NCT 00692393.
OBJECTIVE AND BACKGROUND:Self-expanding metallic stent (SEMS) insertion has been suggested as a promising alternative to emergency surgery for left-sided malignant colonic obstruction (LMCO). ...However, the literature on the long-term impact of SEMS as “a bridge to surgery” is limited and contradictory.
METHODS:From January 1998 to June 2011, we retrospectively identified patients operated on for LMCO with curative intent. The primary outcome criterion was overall survival. Short-term secondary endpoints included the technical success rate and overall success rate and long-term secondary endpoints included 5-year overall survival, 5-year cancer-specific mortality, 5-year disease-free survival, the recurrence rate, and mean time to recurrence. Patients treated with SEMS were analyzed on an intention-to-treat basis. Overall survival was analyzed after using a propensity score to correct for selection bias.
RESULTS:There were 48 patients in the SEMS group and 39 in the surgery-only group. In the overall population, overall survival (P = 0.001) and 5-year overall survival (P = 0.0003) were significantly lower in the SEMS group than in the surgery-only group, and 5-year cancer-specific mortality was significantly higher in the SEMS group (48% vs 21%, respectively (P = 0.02)). Five-year disease-free survival, the recurrence rate, and the mean time to recurrence were better in the surgery-only group (not significant). For patients with no metastases or perforations at hospital admission, overall survival (P = 0.003) and 5-year overall survival (30% vs 67%, respectively, P = 0.001) were significantly lower in the SEMS group than in the surgery-only group.
CONCLUSIONS:Our study results suggest worse overall survival of patients with LMCO with SEMS insertion compared with immediate surgery.
To assess the effect of pelvic drainage after rectal surgery for cancer.
Pelvic sepsis is one of the major complications after rectal excision for rectal cancer. Although many studies have confirmed ...infectiveness of drainage after colectomy, there is still a controversy after rectal surgery.
This multicenter randomized trial with 2 parallel arms (drain vs no drain) was performed between 2011 and 2014. Primary endpoint was postoperative pelvic sepsis within 30 postoperative days, including anastomotic leakage, pelvic abscess, and peritonitis. Secondary endpoints were overall morbidity and mortality, rate of reoperation, length of hospital stay, and rate of stoma closure at 6 months.
A total of 494 patients were randomized, 25 did not meet the criteria and 469 were analyzed: 236 with drain and 233 without. The anastomotic height was 3.5 ± 1.9 cm from the anal verge. The rate of pelvic sepsis was 17.1% (80/469) and was similar between drain and no drain: 16.1% versus 18.0% (P = 0.58). There was no difference of surgical morbidity (18.7% vs 25.3%; P = 0.83), rate of reoperation (16.6% vs 21.0%; P = 0.22), length of hospital stay (12.2 vs 12.2; P = 0.99) and rate of stoma closure (80.1% vs 77.3%; P = 0.53) between groups. Absence of colonic pouch was the only independent factor of pelvic sepsis (odds ratio = 1.757; 95% confidence interval 1.078-2.864; P = 0.024).
This randomized trial suggests that the use of a pelvic drain after rectal excision for rectal cancer did not confer any benefit to the patient.
Background
In two-stage hepatectomy for bilobar liver metastases from colorectal cancer, future liver remnant (FLR) growth can be achieved using several techniques, such as right portal vein ligation ...(RPVL) or right portal vein embolization (RPVE). A few heterogeneous studies have compared these two techniques with contradictory results concerning FLR growth. The objective of this study was to compare FLR hypertrophy of the left hemi-liver after RPVL and RPVE.
Study design
This was a retrospective comparative study using a propensity score of patients who underwent RPVL or RPVE prior to major hepatectomy between January 2010 and December 2020. The endpoints were FLR growth (%) after weighting using the propensity score, which included FLR prior to surgery and the number of chemotherapy cycles. Secondary endpoints were the percentage of patients undergoing simultaneous procedures, the morbidity and mortality, the recourse to other liver hypertrophy procedures, and the number of invasive procedures for the entire oncologic program in intention-to-treat analysis.
Results
Fifty-four consecutive patients were retrospectively included and analyzed, 18 in the RPVL group, and 36 in the RPVE group. The demographic characteristics were similar between the groups. After weighting, there was no significant difference between the RPVL and RPVE groups for FLR growth (%), respectively 32.5% 19.3–56.0% and 34.5% 20.5–47.3% (
p
= 0.221). There was no significant difference regarding the secondary outcomes except for the lower number of invasive procedures in RPVL group (median of 2 2.0, 3.0 in RPVL group and 3 3.0, 3.0 in RPVE group,
p
= 0.001)).
Conclusion
RPVL and RPVE are both effective to provide required left hemi-liver hypertrophy before right hepatectomy. RPVL should be considered for the simultaneous treatment of liver metastases and the primary tumor.
Enhanced recovery programs (ERPs) are associated with a lower morbidity rate and a shorter length of stay. The present study's objective was to determine whether an ERP is feasible and effective for ...patients undergoing early cholecystectomy for grade I or II acute calculous cholecystitis.
A 2-step multicenter study was performed. In the first step (the feasibility study), patients were consecutively included in a dedicated, prospective database from March 2019 until January 2020. The primary endpoint was the ERP's feasibility, evaluated in terms of the number and nature of the ERP components applied. During the second step, the ERP's effectiveness in acute calculous cholecystitis was evaluated in a case-control study. The ERP+ group comprised consecutive patients who were prospectively included from March 2019 to November 2020 and compared with a control (ERP-) group of patients extracted from the ABCAL randomized controlled trial treated between May 2010 and August 2012 and who had not participated in a dedicated ERP.
During the feasibility study, 101 consecutive patients entered the ERP with 17 of the 20 ERP components applied. During the effectiveness study, 209 patients (ERP+ group) were compared with 414 patients (ERP- group). The median length of stay was significantly shorter in the ERP+ group (3.1 vs 5 days; p < 0.001). There were no intergroup differences in the severe morbidity rate, mortality rate, readmission rate, and reoperation rate.
Implementation of an ERP after early cholecystectomy for acute calculous cholecystitis appeared to be feasible, effective, and safe for patients. The ERP significantly decreased the length of stay and did not increase the morbidity rate.
Background
In a recent propensity score study, we established that overall- and disease-free survival were worse after use of a colonic stent (CS) than after emergency surgery for colonic ...obstruction. The present study sought to explain the association between CS use and poor survival by analyzing pathological specimens.
Methods
From January 1998 to December 2011, all patients with left obstructive colon cancer and having been operated on with curative intent were included in the study. The primary end point involved a comparison of pathological data from the CS- and the surgery-only groups in a case-matched analysis (with the groups matched for the T stage). In a series of secondary analyses, we studied a range of factors known to be associated with adverse outcomes (microscopic perforation, vascular embolism, perineural invasion, and lymph node invasion) in the study population as a whole (in order to evaluate stenting as an adverse factor) and in the CS group alone (in order to identify factors associated with a poor prognosis in this specific group of patients).
Results
A total of 84 patients were included in the study (50 in the CS group). Stenting was mentioned in only 70 % of the pathology lab reports (
n
= 35/50). Twenty-five patients in the CS group were matched with 25 patients of the surgery-only group. Tumor ulceration (
p
< 0.0001), peritumor ulceration (
p
< 0.0001), perineural invasion (
p
= 0.008), and lymph node invasion (
p
= 0.005) were significantly more frequent in the CS group. In a multivariate analysis of the CS group, T4 status and tumor size were significant risk factors for microscopic perforation, perineural invasion, and lymph node invasion.
Conclusion
The CS- and surgery-only groups differed significantly in terms of ulceration at or near the tumor, perineural invasion, and lymph node invasion. Explanation of the adverse outcomes associated with CS use will probably require further investigation.
Background Ischemia and necrosis are complications of small bowel obstruction (SBO) and require rapid surgical treatment. At present, there are no sufficiently accurate preoperative biomarkers of ...ischemia or necrosis. The objective of the current study was to evaluate the value of serum procalcitonin levels for predicting conservative management failure and the presence of intraoperatively observed bowel ischemia (reversible or not) in patients with SBO. Study Design One hundred and sixty-six participants of 242 in a randomized controlled trial focusing on the management of SBO (Acute Bowel Obstruction Diagnostic study ABOD, NCT00389116 ) had available data on procalcitonin and were included in the study. The primary study objective was to determine whether serum procalcitonin could identify patients in whom conservative management (CM) failed (the surgical management SM group) and the subset of SM patients with intraoperatively observed ischemia (reversible or not). For the analysis, the patients were divided into subgroups according to the success or failure of CM and (for surgically managed patients) the presence or absence of intraoperative ischemia (reversible or not). Results Procalcitonin levels were higher in the SM group (n = 35) than in the CM group (n = 131) (0.53 vs 0.14 ng/mL; p = 0.031) and higher in the group managed surgically with ischemia (n = 12) than patients managed surgically without intraoperative ischemia (n = 23) (1.16 vs 0.21 ng/mL, respectively; p < 0.001). A multiple logistic regression showed that procalcitonin is a risk factor for CM failure (odds ratio = 3.5; 95% CI, 1.4–8.5; p = 0.006) and for ischemia (reversible or not) (odds ratio = 46.9; 95% CI, 4.0–547.3; p < 0.001). Conclusions Procalcitonin can help predict CM failure and occurrence of bowel ischemia (reversible or not) in SBO patients, but additional studies are needed.
Cross-presentation by the others Mauvais, François-Xavier; van Endert, Peter
Seminars in immunology,
20/May , Letnik:
67
Journal Article
Recenzirano
The critical role of conventional dendritic cells in physiological cross-priming of immune responses to tumors and pathogens is widely documented and beyond doubt. However, there is ample evidence ...that a wide range of other cell types can also acquire the capacity to cross-present. These include not only other myeloid cells such as plasmacytoid dendritic cells, macrophages and neutrophils, but also lymphoid populations, endothelial and epithelial cells and stromal cells including fibroblasts. The aim of this review is to provide an overview of the relevant literature that analyzes each report cited for the antigens and readouts used, mechanistic insight and in vivo experimentation addressing physiological relevance. As this analysis shows, many reports rely on the exceptionally sensitive recognition of an ovalbumin peptide by a transgenic T cell receptor, with results that therefore cannot always be extrapolated to physiological settings. Mechanistic studies remain basic in most cases but reveal that the cytosolic pathway is dominant across many cell types, while vacuolar processing is most encountered in macrophages. Studies addressing physiological relevance rigorously remain exceptional but suggest that cross-presentation by non-dendritic cells may have significant impact in anti-tumor immunity and autoimmunity.
•All myeloid but also some lymphoid populations, endothelial cells and fibroblasts have been reported to cross-present.•Numerous reports document cross-presentation by macrophages.•Evidence of cross-presentation is frequently based on the experimental setup of soluble ovalbumin and OT-I T cell readout.•Vacuolar antigen processing is frequently observed in cross-presenting macrophages.•Few studies undertake rigorous testing of physiological relevance.
Introduction
During the COVID-19 pandemic, cancer patients have been regarded as having a high risk of severe events if they are infected with SARS-CoV-2, particularly those under medical or surgical ...treatment. The aim of this study was to assess the posttreatment risk of infection by SARS-CoV-2 in a population of patients operated on for colorectal cancer 3 months before the COVID-19 outbreak and who after hospitalization returned to an environment where the virus was circulating.
Materials and methods
This French, multicenter cohort study included consecutive patients undergoing elective surgery for colorectal cancer between January 1 and March 31, 2020, at 19 GRECCAR hospitals. The outcome was the rate of COVID-19 infection in this group of patients who were followed until June 15, 2020.
Results
This study included 448 patients, 262 male (58.5%) and 186 female (41.5%), who underwent surgery for colon cancer (
n
= 290, 64.7%), rectal cancer (
n
= 155, 34.6%), or anal cancer (
n
= 3, 0.7%). The median age was 68 years (19–95). Comorbidities were present in nearly half of the patients, 52% were at least overweight, and the median BMI was 25 (12–42). At the end of the study, 448 were alive. Six patients (1.3%) developed COVID-19 infection; among them, 3 were hospitalized in the conventional ward, and none of them died.
Conclusion
The results are reassuring, with only a 1.3% infection rate and no deaths related to COVID-19. We believe that we can operate on colorectal cancer patients without additional mortality from COVID-19, applying all measures aimed at reducing the risk of infection.
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