Publications by authors named "Igor Sielezneff"

53 Publications

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for resectable peritoneal metastases is feasible in elderly patients.

Updates Surg 2021 Apr 6;73(2):719-730. Epub 2021 Feb 6.

Department of General and Digestive Surgery, Timone University Hospital, Aix Marseille Univ, APHM, 264 Rue Saint-Pierre, 13005, Marseille, France.

The aim is to evaluate the feasibility and the prognosis of cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for resectable peritoneal metastases (RPM) in elderly patients. Patients who underwent CRS with HIPEC for RPM between 2012 and 2018 in one tertiary reference center were retrospectively included and divided according to the age: Group A (< 65 years) and Group B (≥ 65 years). Postoperative outcomes and survivals were compared. Ninety-five patients were included in Groups A (n = 65) and B (n = 30). The incidence of comorbidities was significantly higher in elderly patients (65 vs 90%, p = 0.01), but RPM characteristics were similar between groups. There was no difference between groups in terms of postoperative results: 30-day major morbidity (33 vs 23%, p = 0.4), 30-day mortality (0 vs 3%, p = 0.3), mean length of stay (26.7 ± 19.4 vs 22.4 ± 10.3 days, p = 0.3) and readmission's rate (15 vs 33%, p = 0.06). The only one significant difference was the 90-day mortality which never occurred before 65 years but in 10% of elderly patients (p = 0.03). There was no difference regarding recurrence's rate (56 vs 37%, p = 0.1), neither 1-, 3- and 5-year overall survival rates (86, 64 and 52% vs 85, 74% and not reached, p = 0.8) and disease-free survival rates (61, 28 and 28% vs 56, 45% and not reached, p = 0.6). CRS with HIPEC is feasible in elderly patients. Since the 90-day mortality appeared to be higher in elderly patients, additional criteria are necessary to improve the selection of elderly patients for this major surgery.
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http://dx.doi.org/10.1007/s13304-020-00966-5DOI Listing
April 2021

End Colostomy With or Without Mesh to Prevent a Parastomal Hernia (GRECCAR 7): A Prospective, Randomized, Double Blinded, Multicentre Trial.

Ann Surg 2021 12;274(6):928-934

Department of Digestive Surgery, CHU Nimes, Univ Montpellier, Nimes, France.

Objective: To evaluate whether systematic mesh implantation upon primary colostomy creation was effective to prevent PSH.

Summary Of Background Data: Previous randomized trials on prevention of PSH by mesh placement have shown contradictory results.

Methods: This was a prospective, randomized controlled trial in 18 hospitals in France on patients aged ≥18 receiving a first colostomy for an indication other than infection. Participants were randomized by blocks of random size, stratified by center in a 1:1 ratio to colostomy with or without a synthetic, lightweight monofilament mesh. Patients and outcome assessors were blinded to patient group. The primary endpoint was clinically diagnosed PSH rate at 24 months of the intention-to-treat population. This trial was registered at ClinicalTrials.gov, number NCT01380860.

Results: From November 2012 to October 2016, 200 patients were enrolled. Finally, 65 patients remained in the no mesh group (Group A) and 70 in the mesh group (Group B) at 24 months with the most common reason for drop-out being death (n = 41). At 24 months, PSH was clinically detected in 28 patients (28%) in Group A and 30 (31%) in Group B [P = 0.77, odds ratio = 1.15 95% confidence interval = (0.62;2.13)]. Stoma-related complications were reported in 32 Group A patients and 37 Group B patients, but no mesh infections. There were no deaths related to mesh insertion.

Conclusion: We failed to show efficiency of a prophylactic mesh on PSH rate. Placement of a mesh in a retro-muscular position with a central incision to allow colon passage cannot be recommended to prevent PSH. Optimization of mesh location and reinforcement material should be performed.
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http://dx.doi.org/10.1097/SLA.0000000000004371DOI Listing
December 2021

Ten-year Evaluation of a Large Retrospective Cohort Treated by Sacral Nerve Modulation for Fecal Incontinence: Results of a French Multicenter Study.

Ann Surg 2020 Jul 24. Epub 2020 Jul 24.

Normandie Univ, UNIROUEN, CHU Rouen, Department of Digestive Physiology and CIC-CRB 1404, Rouen, France.

Objective: The aim of this study was to assess the effectiveness of sacral nerve modulation (SNM) in a large cohort of patients implanted for at least 10 years, quantify adverse event rates, and identify predictive factors of long-term success.

Summary Background Data: Few studies have evaluated the long-term success of SNM.

Methods: Data collected prospectively from patients implanted for fecal incontinence (FI) in 7 French centers between January 1998 and December 2008 were retrospectively analyzed. Patient FI severity scores were assessed before and 10 years after implantation. The main evaluation criterion was the success of SNM defined by the continuation of the treatment without additional therapies. The secondary evaluation criteria were the rate of device revisions and explantations. Preoperative predictors of success at 10 years were sought.

Results: Of the 360 patients (27 males, mean age: 59 ± 12 years) implanted for FI, 162 (45%) had a favorable outcome 10 years post-implantation, 115 (31.9%) failed, and 83 (23.1%) were lost to follow-up. The favorable outcome derived from the time-to-event Kaplan-Meier curve at 10 years was 0.64 (95% CI 0.58-0.69). FI severity scores were significantly better 10 years post-implantation compared to preimplantation (7.4 ± 4.3 vs 14.0 ± 3.2; P < 0.0001). During the 10-year follow-up, 233 patients (64.7%) had a surgical revision and 94 (26.1%) were explanted. A history of surgery for FI and sex (male) were associated with an increased risk of an unfavorable outcome.

Conclusions: Long-term efficacy was maintained in approximately half of the FI patients treated by SNM at least 10 years post-implantation.
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http://dx.doi.org/10.1097/SLA.0000000000004251DOI Listing
July 2020

Impact of hospital volume on outcomes after emergency management of obstructive colon cancer: a nationwide study of 1957 patients.

Int J Colorectal Dis 2020 Oct 5;35(10):1865-1874. Epub 2020 Jun 5.

Department of Digestive Surgery, Pitié Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France.

Purpose: Volume-outcome relationship is well established in elective colorectal surgery for cancer, but little is known for patients managed for obstructive colon cancer (OCC). We aimed to compare the management and outcomes according to the hospital volume in this particular setting.

Methods: Patients managed for OCC between 2005 and 2015 in centers of the French National Surgical Association were retrospectively analyzed. Hospital volume was dichotomized between low and high volume on the median number of patients included per center during the study period.

Results: A total of 1957 patients with OCC were managed in 56 centers with a median number of 28 (1-123) patients per center: 298 (15%) were treated in low-volume hospitals (LVHs) and 1659 (85%) in high-volume hospitals (HVHs). Patients in LVH were significantly younger, and had fewer comorbidities and synchronous metastases. Proximal diverting stoma was the preferred surgical option in LVH (p < 0.0001), whereas tumor resection with primary anastomosis was more frequently performed in HVH (p < 0.0001). Cumulative morbidity (59 vs. 50%, p = 0.003), mortality (13 vs. 8%, p = 0.03), and length of hospital stay (22 ± 19 vs. 18 ± 14 days, p = 0.002) were significantly higher in LVH. At multivariate analysis, LVH was a predictor for cumulative morbidity (p < 0.0001) and mortality (p = 0.03). There was no difference between the two groups for tumor resection and stoma rates, and for oncological outcomes.

Conclusions: The hospital volume has no impact on outcomes after the first-stage surgery in OCC patients. When all surgical stages are considered, hospital volume influences cumulative postoperative morbidity and mortality but has no impact on oncological outcomes.
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http://dx.doi.org/10.1007/s00384-020-03602-1DOI Listing
October 2020

Efficacy and safety of sacral nerve modulation for faecal incontinence after pelvic radiotherapy.

Radiother Oncol 2020 05 12;146:167-171. Epub 2020 Mar 12.

Department of Digestive Physiology, University Hospital of Rennes Pontchaillou, CIC1414, INPHY, INSERM U1241, University of Rennes 1, France; Department of Gastroenterology, University Hospital of Rennes Pontchaillou, CIC1414, INPHY, INSERM U1241, University of Rennes 1, France. Electronic address:

Objective: To assess the efficacy and safety of sacral nerve modulation (SNM) in patients with faecal incontinence (FI) after pelvic radiotherapy in comparison with results of SNM for FI related to other conditions.

Methods: Prospectively collected data from patients who underwent SNM therapy between January 2010 and December 2015 at 7 tertiary colorectal units were reviewed retrospectively. Patients with FI following pelvic radiotherapy were identified and matched (1:2) for age and sex with 38 patients implanted over the same period for FI without previous radiotherapy. The treatment was considered favourable if the patient reported any therapeutic benefit from SNM, had no further complaints or interventions and did not consider stopping the treatment. Long-term results, surgical revision and definitive explantation rates were compared.

Results: Among 352 patients who received a permanent SNM implant, 19 (5.4%) had FI following pelvic radiotherapy. After a mean follow-up of 3.5 ± 1.9 years, the cumulative successful treatment rates were similar between the groups (p = 0.60). For patients with FI following pelvic radiotherapy, the cumulative success rates were 99.4% [85.4-99.8], 96.7% [78.1-99.6], 91.7% [70.4-98.1] and 74.6% [48.4-94.8] at 1, 2, 3 and 5 years respectively. The revision and definitive explantation rates for infection did not differ significantly.

Conclusion: The long-term success rate of SNM for FI after pelvic radiotherapy is similar to that of SNM for FI related to other more frequent conditions. Our study suggests that FI after pelvic radiotherapy could be improved with SNM without an increased risk of complication.
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http://dx.doi.org/10.1016/j.radonc.2020.02.020DOI Listing
May 2020

Prognostic factors and patterns of recurrence after emergency management for obstructing colon cancer: multivariate analysis from a series of 2120 patients.

Langenbecks Arch Surg 2019 Sep 10;404(6):717-729. Epub 2019 Oct 10.

Sorbonne Université, Assistance Publique Hôpitaux de Paris, Department of Digestive Surgery, Pitié Salpêtrière University Hospital, Paris, France.

Purpose: At equal TNM stage, obstructing colon cancer (OCC) is associated with worse prognosis in comparison with uncomplicated cancer. Our aim was to identify prognostic factors of overall (OS) and disease-free survival (DFS) in patients treated for OCC.

Methods: From 2000 to 2015, 2325 patients were treated for OCC in French surgical centers, members of the French National Surgical Association (AFC). Patients with palliative management were excluded. The main endpoints were OS and DFS. A multivariate analysis, using Cox proportional hazards regression model, was performed to determine independent prognostic factors.

Results: The cohort included 2120 patients. The median of follow-up was 13.2 months. In multivariate analysis, age > 75 years, ASA score ≥ 3, ECOG score ≥ 3, right-sided colon cancer, presence of synchronous metastases, anastomotic leakage, and absence of adjuvant chemotherapy were independent OS factors. Age > 75 years, ASA score ≥ 3, right-sided colon cancer, presence of synchronous metastases, and absence of postoperative chemotherapy were independent factors of poor OS after exclusion of patients who died postoperatively. Age ≥ 75 years, ASA score ≥ 3, ECOG score ≥ 3, right-sided colon cancer, lymph node involvement, presence of vascular, lymphatic or perineural invasion, less than 12 harvested lymph nodes, and absence of adjuvant chemotherapy were independent DFS factors.

Conclusions: Management of OCC should take into account prognostic factors related to the patient (age, comorbidities), tumor location, and tumor stage. Adjuvant chemotherapy administration plays an important role. For patients undergoing initial defunctionning stoma, neoadjuvant chemotherapy could be an option to improve prognosis.
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http://dx.doi.org/10.1007/s00423-019-01819-5DOI Listing
September 2019

Is Sacral Nerve Modulation a Good Option for Fecal Incontinence in Men?

Neuromodulation 2019 Aug 18;22(6):745-750. Epub 2019 Jul 18.

Department of Digestive Physiology and Department of Gastroenterology, University Hospital of Rennes Pontchaillou, CIC1414, INPHY, INSERM U1241, University of Rennes 1, Rennes, France.

Objective: The objective was to assess the efficacy and the safety of sacral nerve modulation (SNM) in men with fecal incontinence (FI) compared with those of SNM in women.

Method: Prospectively collected data from patients from seven tertiary colorectal units who underwent an implant procedure between January 2010 and December 2015 were reviewed retrospectively. Outcomes and surgical revision and definitive explantation rates were compared between men and women.

Results: A total of 469 patients (60 men [12.8%]; mean age = 61.4 ± 12.0 years) were included in the study, 352 (78.1%) (31 men [8.8%]) of whom received a permanent implant. The ratio of implanted/tested men was significantly lower than the ratio of implanted/tested women (p = 0.0004). After a mean follow-up of 3.4 ± 1.9 years, the cumulative successful treatment rates tended to be less favorable in men than in women (p = 0.0514): 88.6% (75.6-95.1), 75.9% (60.9-86.4), 63.9% (48.0-77.3), and 43.9% (26.7-62.7) at one, two, three, and five years, respectively, in men; 92.0% (89.1-94.2), 84.2% (80.3-87.4), 76.8% (72.3-80.7), and 63.6% (57.5-69.3) at one, two, three, and five years, respectively, in women. The revision rate for infection and the definitive explantation rate for infection were higher in men than in women (p = 0.0001 and p = 0.0024, respectively).

Conclusion: Both short- and long-term success rates of SNM for FI were lower in men than in women. The revision and definitive explantation for long-term infection rates were significantly higher in men.
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http://dx.doi.org/10.1111/ner.13017DOI Listing
August 2019

Emergency Surgery for Obstructive Colon Cancer in Elderly Patients: Results of a Multicentric Cohort of the French National Surgical Association.

Dis Colon Rectum 2019 08;62(8):941-951

Department of Digestive Surgery, Sorbonne Université, Assistance Publique Hôpitaux de Paris, Pitié Salpêtrière University Hospital, Paris, France.

Background: Although elderly patients constitute most of the patients undergoing surgery for obstructed colon cancer, available data in the literature are very limited.

Objective: The purpose of this study was to assess the management and outcomes of elderly patients treated for obstructed colon cancer.

Design: This was a multicenter, retrospective cohort study.

Settings: Between 2000 and 2015, 2325 patients managed for an obstructed colon cancer in member centers of the French National Surgical Association were identified. Data were collected by each center on a voluntary basis after institutional approval. Bowel obstruction was defined clinically and confirmed by imaging.

Patients: Three age groups were defined, including patients <75 years, 75 to 84 years, and ≥85 years.

Main Outcome Measures: Postoperative and oncologic results in elderly patients with an obstructed colon cancer were measured. Relative survival was calculated as the ratio of the overall survival with the survival that would have been expected based on the corresponding general population.

Interventions: A total of 302 patients (13%) underwent colonic stent insertion, and 1992 (87%) underwent surgery as emergency procedure.

Results: A total of 2294 patients were analyzed (<75 y, n = 1200 (52%); 75-84 y, n = 650 (28%); and ≥85 y, n = 444 (20%)). Elderly patients were more likely to be women (p < 0.0001), to have proximal colon cancer (p < 0.0001), and to have a higher incidence of comorbidities (p < 0.0001). The use of colonic stent or the type of surgery was identical regardless of age. In patients with resected colon cancer, elderly patients had less stage IV disease (p < 0.0001). The absence of tumor resection (p < 0.0001) and definitive stoma rate increased with age (p < 0.0001). Postoperative mortality and morbidity were significantly higher in elderly patients (p < 0.0001), but surgical morbidity was similar across age groups (p = 0.60). Postoperative morbidity was correlated to the 6-month mortality rate in elderly (p < 0.0001). Overall and disease-free survivals were significantly lower in more elderly patients (p < 0.0001) but relative survival was not (p = 0.09).

Limitations: It is quite difficult to know how to interpret these data as a whole, given the inherent bias in the study population, lack of ability to stratify by performance status, and long study period duration.

Conclusions: Elderly patients have high morbidity with lower survival in the highest age ranges of elderly subgroups. These data should be considered when deciding on an operative approach. See Video Abstract at http://links.lww.com/DCR/A964.
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http://dx.doi.org/10.1097/DCR.0000000000001421DOI Listing
August 2019

[Emborrhoid: Rectal arteries embolization for hemorrhoid treatment].

Presse Med 2019 Apr 3;48(4):454-459. Epub 2019 May 3.

Assistance publique-hôpitaux de Marseille, hôpital de la Timone, service d'imagerie diagnostic et interventionnelle, 264, rue Sainte-Pierre, 13005 Marseille, France; Université Aix-Marseille, CERIMED, faculté de médecine, EA 4264, laboratoire d'imagerie interventionnelle expérimentale (LIIE), 27, boulevard Jean-Moulin, 13005 Marseille, France.

Although hemorrhoids are recognized as a very common cause of rectal bleeding and known for a long time, its treatment has evolved dramatically over the last twenty years. Among the new minimally invasive methods, the "Emborrhoid" technique consists into selective embolization of hemorrhoidal arteries, branches arising from the superior rectal arteries using microcoils. This technique is based on a demonstrated pathophysiological concept of arterial network hypertrophy in hemorrhoid disease. This technique was evaluated in an animal model and then in clinical research on more than 100 patients. No ischemic complications were identified. Studies describe an improvement of 60 to 80% of the symptoms, with on average 30% recurrences at two years. The recurrence rae is likely related to a technically incomplete embolization. Future prospects are focused on more selective embolization with Particulate embolic agents.
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http://dx.doi.org/10.1016/j.lpm.2019.04.011DOI Listing
April 2019

Right-sided vs. left-sided obstructing colonic cancer: results of a multicenter study of the French Surgical Association in 2325 patients and literature review.

Int J Colorectal Dis 2019 Jun 2;34(6):1021-1032. Epub 2019 Apr 2.

Sorbonne Université, Assistance Publique Hôpitaux de Paris, Department of Digestive and Hepatopancreato-Biliary Surgery, Pitié Salpêtrière University Hospital, 47-83 Bd de l'Hôpital, 75651, Paris Cedex 13, France.

Purpose: Few studies compared management and outcomes of obstructing colonic cancer (OCC), according to the tumor site. Our aim was to compare patient and tumor characteristics, postoperative and pathological results, and oncological outcomes after emergency management of right-sided vs. left-sided OCC.

Methods: A national cohort study including all consecutive patients managed for OCC from 2000 to 2015 in French surgical centers members of the French National Surgical Association (AFC).

Results: During the study period, 2325 patients with OCC were divided in right-sided (n = 819, 35%) and left-sided (n = 1506, 65%) locations. Patients with right-sided OCC were older, more frequently females, and associated with comorbidities, history of cancer, or previous laparotomy. Surgical management was more frequently performed for right-sided than left-sided OCC (99 vs. 96%, p < 0.0001). Tumor resection was more frequently performed in right-sided OCC (95 vs. 90%, p < 0.0001). Among the resected patients, primary anastomosis was more frequently performed in case of right-sided OCC (86 vs. 62%, p < 0.0001). Definitive stoma rate was lower in right-sided location (17 vs. 46%, p < 0.0001). There was no significant difference between locations in terms of cumulative morbidity, anastomotic leak, unplanned reoperation, and mortality. Five-year overall and disease-free survival rates were significantly lower in right-sided OCC (43 and 36%) than in left-sided OCC (53 and 46%, p < 0.0001 and p = 0.001, respectively).

Conclusions: Although patients with right-sided OCC are frailer than left-sided OCC, tumor resection and anastomosis are more frequently performed, without difference in surgical results. However, right-sided OCC is associated with worse prognosis than distal location.
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http://dx.doi.org/10.1007/s00384-019-03286-2DOI Listing
June 2019

30-Day Postoperative Morbidity of Emergency Surgery for Obstructive Right- and Left-Sided Colon Cancer in Obese Patients: A Multicenter Cohort Study of the French Surgical Association.

Dig Surg 2020 2;37(2):111-118. Epub 2019 Apr 2.

Department of Digestive Surgery, Medecine Sorbonne University, Assistance Publique Hôpitaux de Paris, Pitié Salpêtrière University Hospital, Paris, France,

Background: Emergency surgery impairs postoperative outcomes in colorectal cancer patients. No study has assessed the relationship between obesity and postoperative results in this setting.

Objective: To compare the results of emergency surgery for obstructive colon cancer (OCC) in an obese patient population with those in overweight and normal weight patient groups.

Methods: From 2000 to 2015, patients undergoing emergency surgery for OCC in French surgical centers members of the French National Surgical Association were included. Three groups were defined: normal weight (body mass index [BMI] < 25.0 kg/m2), overweight (BMI 25.0-29.9 kg/m2), and obese (BMI ≥30.0 kg/m2).

Results: Of 1,241 patients, 329 (26.5%) were overweight and 143 (11.5%) were obese. Obese patients had significantly higher American society of anesthesiologists score, more cardiovascular comorbidity and more hemodynamic instability at presentation. Overall postoperative mortality and morbidity were 8 and 51%, respectively, with no difference between the 3 groups. For obese patients with left-sided OCC, stoma-related complications were significantly increased (8 vs. 5 vs. 15%, p = 0.02).

Conclusion: Compared with lower BMI patients, obese patients with OCC had a more severe presentation at admission but similar surgical management. Obesity did not increase 30-day postoperative morbidity except stoma-related complications for those with left-sided OCC.
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http://dx.doi.org/10.1159/000497450DOI Listing
December 2020

What is the Best Option Between Primary Diverting Stoma or Endoscopic Stent as a Bridge to Surgery with a Curative Intent for Obstructed Left Colon Cancer? Results from a Propensity Score Analysis of the French Surgical Association Multicenter Cohort of 518 Patients.

Ann Surg Oncol 2019 Mar 8;26(3):756-764. Epub 2019 Jan 8.

Sorbonne University, Assistance Publique Hôpitaux de Paris, Department of Digestive and Hepato-Pancreato-Biliary Surgery, Pitié-Salpêtrière University Hospital, Paris, France.

Background: Endoscopic stent (ES) as a bridge to surgery in obstructed left colon cancer (OLCC) is controversial. Our goal was to compare the operative and oncological results of primary diverting colostomy (PDC) and ES for the curative treatment of OLCC.

Methods: Between 2000 and 2015, patients who underwent PDC or ES in a curative intent for OLCC at member centers of the French Surgical Association were included. Patients with unresectable tumors and/or synchronous metastases were excluded. Comparisons between the two groups were performed after ponderation with propensity score for: demographic and tumor characteristics, operative, and oncological results.

Results: A total of 518 patients were included: PDC (n = 327); ES (n = 191). The demographic characteristics were similar between the groups. ES failed in 23% of the patients (11% perforation). Cumulative tumor resection rates were 80% and 86% after PDC and ES, respectively (p = 0.049). The rates of primary anastomosis were 57% in the PDC group and 40% in the ES group (p < 0.0001). The permanent stoma rates were similar between the two groups (29% vs. 28%, p = 0.0586). Cumulative overall, surgical, and medical complications were significantly higher in PDC group. The resected tumors were significantly smaller and less frequently perforated and metastatic in the PDC group. The median overall survival was significantly higher after PDC (123.6 vs. 58.5 months, p = 0.046), whereas the median disease-free survival was similar between the two groups (54.1 vs. 53.6 months, p = 0.646).

Conclusions: Although endoscopic stenting is associated with better surgical outcomes than diverting stoma, it may negatively impact histological features and overall survival.
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http://dx.doi.org/10.1245/s10434-018-07139-0DOI Listing
March 2019

Surgical management of obstructive right-sided colon cancer at a national level results of a multicenter study of the French Surgical Association in 776 patients.

Eur J Surg Oncol 2018 10 6;44(10):1522-1531. Epub 2018 Jul 6.

Medecine Sorbonne University, Assistance Publique Hôpitaux de Paris, Department of Digestive and Hepato-Pancreato-Biliary Surgery, Pitié-Salpêtrière University Hospital, Paris VI University Institute of Cancerology, Paris, France. Electronic address:

Aim: To report the results of surgery for obstructive right colon cancer (ORCC) and to identify risk factors associated with worse outcomes that may help surgeons to choose the best surgical option.

Methods: This is a retrospective national cohort study, including all patients operated on for ORCC from 2000 to 2015. Those treated with colonic stent or symptomatic treatment were excluded. We described outcomes after surgery for ORCC and performed multivariate analyses for mortality, morbidity and survival.

Results: Among 776 patients analyzed, 716 (92%) had their primary tumor removed, with primary anastomosis in 582 (82%). The remaining 194 underwent anastomosis with loop ileostomy (n = 21), resection with double-end stoma (n = 113), defunctioning stoma without resection (n = 48) and ileocolic by-pass (n = 12). Postoperative mortality, morbidity and anastomotic leak rates were 10%, 51% and 14%, respectively. In multivariate analysis, age >70, ASA score ≥3 and hemodynamic instability were predictors of postoperative mortality whereas ASA score ≥3, hemodynamic instability and intra-operative complications were predictors of severe morbidity. No factors were correlated with anastomotic leak. After a median follow-up of 26 months, 8% of patients were alive with a permanent stoma. Five-year overall, disease-free and cancer-specific survival was 42%, 42% and 62%, respectively. In multivariate analysis, peritonitis, synchronous metastases and absence of adjuvant chemotherapy were predictors of decreased overall survival.

Conclusions: Emergency surgery for ORCC is associated with high mortality and morbidity. Two third of patients with ORCC can be managed with resection and primary anastomosis. For high-risk patients, a staged surgical management may be discussed.
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http://dx.doi.org/10.1016/j.ejso.2018.06.027DOI Listing
October 2018

A comparison of surgical devices for grade II and III hemorrhoidal disease. Results from the LigaLongo Trial comparing transanal Doppler-guided hemorrhoidal artery ligation with mucopexy and circular stapled hemorrhoidopexy.

Int J Colorectal Dis 2018 Oct 28;33(10):1479-1483. Epub 2018 May 28.

Colorectal Unit, Institut des Maladies de l'Appareil Digestif (IMAD), University Hospital of Nantes, Nantes, France.

Purpose: Little is presently known on the impact of device type for Doppler-guided hemorrhoidal artery ligation/mucopexy (DGHAL) or circular stapled hemorrhoidopexy (CSH) when a surgical treatment is considered for hemorrhoidal disease (HD). In this study, we aimed to compare the outcome in terms of adverse events and recurrence rate, of patients included in the multicenter LigaLongo RCT ( ClinicalTrials.gov NCT01240772) according to the type of devices used.

Methods: In the DGHAL arm (N = 193), the procedure was done with transanal hemorrhoidal dearterialization (THD)™ (THD, Correggio, Italy) (104 patients) and with HAL-RAR™ (Agency for Medical Innovations (AMI) GmbH, Feldkirch, Austria) (89 patients). In the CSH arm (N = 184), procedure for prolapse and hemorrhoids (PPH)-03™ (Ethicon Endo-Surgery, Cincinnati OH) and hemorrhoidopexy and prolapse (HEM)™ (Covidien, Inc.) staplers were used in respectively 106 and 78 cases. Surgery-related morbidity at 90 postoperative days (POD) based on the Clavien-Dindo procedure-related complication score and clinical outcome in terms of recurrence and reoperation rate at 12 postoperative months (POM) was collected.

Results: Three hundred and seventy-seven patients were randomized according to HD grade. In the DGHAL arm, the number of ligations and mucopexies was higher in the AMI group (p < 0.0001); at 90 POD, the overall morbidity was similar between the two groups. In the CSH arm, donut sizes were similar; at 90 POD, the PPH group had a higher risk of postoperative grade 1 morbidity (anal urgency or incontinence) compared to the HEM group (p = 0.003). At 12 POM, no statistical difference was found between the two groups of each arm in terms of grade III recurrence or reoperation.

Conclusion: Postoperative morbidity and outcome at 1 year were similar regardless of the type of devices used. These findings suggest that device type has little impact on HD treatment results.

Trial Registration: clinicaltrials.gov -Identifier NCT01240772.
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http://dx.doi.org/10.1007/s00384-018-3093-8DOI Listing
October 2018

Embolization of the Superior Rectal Arteries for Hemorrhoidal Disease: Prospective Results in 25 Patients.

J Vasc Interv Radiol 2018 06 30;29(6):884-892.e1. Epub 2018 Apr 30.

Department of Interventional Radiology, Marseille Public University Hospital System, La Timone University Hospital, 264 Rue Saint Pierre, Marseille 13385, Cedex 05, France; Experimental Interventional Imaging Laboratory, Aix Marseille University, Marseille, France.

Purpose: To evaluate efficacy and safety of superior rectal artery embolization of hemorrhoidal disease as a first-line invasive treatment.

Materials And Methods: This prospective study was conducted between 2014 and 2015 on 25 consecutive patients (16 men and 9 women with a mean age of 53 y [range, 30-76 y]) with grade II-III hemorrhoids refractory to medical treatment. A transfemoral superselective superior rectal artery branch embolization was performed using 2- and 3-mm diameter microcoils. Over the following 12 months, clinical outcomes were evaluated using the French bleeding score, Goligher prolapse score, visual analog scale (VAS) score for pain, quality-of-life score. The primary endpoint was relief of symptoms by 12 months based on a 2-point minimum improvement on VAS score and bleeding score.

Results: At 12 months after embolization, clinical success was obtained in 18 patients (72%), 8 of whom had 2 embolizations. VAS score decreased from 4.6 to 2.3 (P < .01), and bleeding score decreased from 5.5 to 2.3 (P < .01). Quality-of-life and prolapse scores also showed improvement (P < .05), and no patients experienced any early or late complications. Complete clinical failure was observed in 7 patients. After coil embolization, the collateral supply to the hemorrhoidal cushions was significantly related to any recurrence (P = .001).

Conclusions: Hemorrhoidal artery coil embolization was found to be a safe and effective treatment for grade II-III hemorrhoids.
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http://dx.doi.org/10.1016/j.jvir.2018.01.778DOI Listing
June 2018

Fibrin-bearing microparticles: marker of thrombo-embolic events in pancreatic and colorectal cancers.

Oncotarget 2017 Nov 26;8(57):97394-97406. Epub 2017 Oct 26.

Aix Marseille Univ, INSERM UMR-S1076, VRCM, Marseille, France.

Background: Microparticles (MPs) are plasma membrane-derived extracellular vesicles present in the bloodstream. We have described a specific signature of MPs, called microparticulosome, in colorectal (CRC) and pancreatic (PC) cancers. We observed that levels of fibrin-bearing MPs were significantly increased in patients suffering from PC and CRC in comparison with control groups. Here, we hypothesised that fibrin-MPs may constitute a relevant biomarker of thrombosis associated with cancer. The objective was to compare the microparticulosome signature between patients presenting with thrombo-embolic event and those without.

Methods: Patients with CRC and PC were prospectively included and divided in those with thrombo-embolic events (Group A) and those without (Group B).MPs were analyzed by flow cytometer, combining the analysis of Annexin V-positive with characterization of their origin and determination of their procoagulant activities. D-dimer levels were measured in the same samples.

Results: We included 118 patients, divided in 19 patients with thrombo embolic event and 99 patients without. Fibrin-bearing MPs levels were significantly higher in presence of thrombo-embolic events, contrary to D-dimers levels. Fibrin-bearing MPs were more frequently produced by erythrocytes, endothelial cells or Ep-CAM+cells than platelets or leukocytes. Overall survival was shorter in case of thrombo-embolic events than without. The most frequent genes expressed by MPs derived from PC or CRC were implicated in metastatic diffusion of tumor cells, drug resistance, coagulation and inflammation.

Conclusion: Circulating MPs, particularly fibrin-bearing MPs, could be used as a new biomarker to predict cancer-associated thrombo-embolic events and poor survival.
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http://dx.doi.org/10.18632/oncotarget.22128DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5722571PMC
November 2017

Hartmann's Procedure or Primary Anastomosis for Generalized Peritonitis due to Perforated Diverticulitis: A Prospective Multicenter Randomized Trial (DIVERTI).

J Am Coll Surg 2017 Dec 22;225(6):798-805. Epub 2017 Sep 22.

Department of Digestive Surgery, Rouen University Hospital, Rouen, France. Electronic address:

Background: 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.

Study Design: 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.

Results: 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).

Conclusions: 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.
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http://dx.doi.org/10.1016/j.jamcollsurg.2017.09.004DOI Listing
December 2017

Temporary successful results of ventral rectopexy for enterocele surgical correction, about 138 patients.

Int J Colorectal Dis 2017 Nov 12;32(11):1569-1575. Epub 2017 Aug 12.

Aix-Marseille Université, 13284, Marseille, France.

Purpose: This work aimed to analyse short- and long-term results of enterocele surgical treatment by ventral rectopexy.

Methods: All females who underwent ventral rectopexy for enterocele in our department were included. All patients underwent standardized preoperative evaluation. Data was retrospectively collected, after examination of patients or by telephone survey. Postoperative evaluation was performed by an independent observer.

Results: One hundred thirty-eight females (median age = 63 years [21-86 years]) were included. They were postmenopausal and multiparous in 94 and 70% of cases, respectively. Pelvic pressure, vaginal prolapse, or the both were observed in 28, 16 or 56% of the patients, respectively. The most frequent associated symptoms were dyschezia (63%) and faecal incontinence (30%). On preoperative workup, enterocele was isolated in two cases. Rectocele, internal rectal prolapse and cervicocystoptosis were the most frequently associated pelvic floor disorders. Ventral rectopexy was performed through laparoscopy in 128 patients (93%). In the short term, all pelvic symptoms were significantly improved, except urinary incontinence. At the end of follow-up (56 months [7-125]), specific symptoms and dyschezia were still significantly improved. Secondary failure was reported in 31% of patients. By multivariate analysis, two predictive factors for long-term failure were found: diagnosis of rectocele on preoperative MRI (odd ratio = 15; 95% CI 1.4-163; p = 0.03) and conversion into open surgery (odd ratio = 8; 95% CI 1.4-43; p = 0.02).

Conclusion: This study suggests that ventral rectopexy is an effective treatment of enterocele, but secondary failure can be observed. Patients should be informed of the potential risk of long-term degradation.
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http://dx.doi.org/10.1007/s00384-017-2887-4DOI Listing
November 2017

Brain metastases from colorectal cancer: characteristics and management.

ANZ J Surg 2018 Mar 7;88(3):140-145. Epub 2017 Jul 7.

Department of Digestive and General Surgery, Timone Hospital, Aix-Marseille University, Marseille, France.

Background: Brain metastases (BMs) are the most common intracranial neoplasms in adults, but they rarely arise from colorectal cancer (CRC). The objective of this study was to report an overview of the characteristics and current management of CRC BMs.

Methods: A systematic review on CRC BMs was performed using Medline database from 1983 to 2015. The search was limited to studies published in English. Review articles, not relevant case report or studies or studies relating to animal and in vitro experiments were excluded.

Results: BMs occurred in 0.06-4% of patients with CRC. Most BMs were metachronous and were associated with lung (27-92%) and liver (12-80%) metastases. Treatment options depended on the number of BMs, the general conditions of the patient and the presence of other metastases. Most frequent treatment was whole-brain radiotherapy (WBRT) alone (36%), with median overall survival comprised between 2 and 9 months. Median overall survival was better after surgery alone (from 3 to 16.2 months), or combined with WBRT (from 7.6 to 14 months). After stereotactic radiosurgery alone, overall survival could reach 9.5 months. Many favourable prognostic factors were identified, such as high Karnofsky performance status, low recursive partitioning analysis classes, lack of extracranial disease, low number of BMs and possibility to perform surgical treatment.

Conclusion: BMs from CRC are rare. In the presence of favourable prognostic factors, an aggressive management including surgical resection with or without WBRT or stereotactic radiosurgery can improve the overall survival.
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http://dx.doi.org/10.1111/ans.14107DOI Listing
March 2018

Early Enteral Versus Total Parenteral Nutrition in Patients Undergoing Pancreaticoduodenectomy: A Randomized Multicenter Controlled Trial (Nutri-DPC).

Ann Surg 2016 Nov;264(5):731-737

*Department of Hepato-Biliary and Pancreatic Surgery, Edouard Herriot Hospital, HCL, UCBL1, Lyon, France†Department of Digestive and General Surgery, Hôpital C. Huriez CHRU, Lille, France‡Department of Digestive Surgery, Hôpital Cochin - St-Vincent de Paul, Paris, France§Department of Digestive Surgery, CHU Timone, Marseille, France¶Department of Digestive Surgery, CHU Dupuytren, Limoges, France||Department of Digestive Surgery and Liver Transplantation, Hôpital de la Croix Rousse, Lyon, France**Pole Information Médicale Evaluation Recherche, HCL, Lyon, France††Department of Hepato-Biliary and Pancreatic Surgery, APHP, Hôpital Beaujon, Clichy, France‡‡Department of Digestive Surgery, APHP, Hôpital Lariboisières, Paris, France§§Department of Digestive Pathology, Surgery Unit, CHU Clermont Ferrand Hôtel Dieu NHE, Clermont Ferrand, France.

Objectives: The aim of this study was to compare nasojejunal early enteral nutrition (NJEEN) with total parenteral nutrition (TPN), after pancreaticoduodenectomy (PD), in terms of postoperative complications.

Background: Current nutritional guidelines recommend the use of enteral over parenteral nutrition in patients undergoing gastrointestinal surgery. However, the NJEEN remains controversial in patients undergoing PD.

Methods: Multicenter, randomized, controlled trial was conducted between 2011 and 2014. Nine centers in France analyzed 204 patients undergoing PD to NJEEN (n = 103) or TPN (n = 101). Primary outcome was the rate of postoperative complications according to Clavien-Dindo classification. Successful NJEEN was defined as insertion of a nasojejunal feeding tube, delivering at least 50% of nutritional needs on PoD 5, and no TPN for more than consecutive 48 hours.

Results: Postoperative complications occurred in 77.5% [95% confidence interval (95% CI) 68.1-85.1] patients in the NJEEN group versus 64.4% (95% CI 54.2-73.6) in TPN group (P = 0.040). NJEEN was associated with higher frequency of postoperative pancreatic fistula (POPF) (48.1% vs 27.7%, P = 0.012) and higher severity (grade B/C 29.4% vs 13.9%; P = 0.007). There was no significant difference in the incidence of post-pancreatectomy hemorrhage, delayed gastric emptying, infectious complications, the grade of postoperative complications, and the length of postoperative stay. A successful NJEEN was achieved in 63% patients. In TPN group, average energy intake was significantly higher (P < 0.001) and patients had an earlier recovery of oral feeding (P = 0.0009).

Conclusions: In patients undergoing PD, NJEEN was associated with an increased overall postoperative complications rate. The frequency and the severity of POPF were also significantly increased after NJEEN. In terms of safety and feasibility, NJEEN should not be recommended.
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http://dx.doi.org/10.1097/SLA.0000000000001896DOI Listing
November 2016

Laparoscopy could be the best approach to treat colorectal cancer in selected patients aged over 80 years: Outcomes from a multicenter study.

Dig Liver Dis 2017 Jan 22;49(1):84-90. Epub 2016 Sep 22.

Department of Gastroenterology and Digestive Oncology, University Hospital of St Etienne, University Jean Monnet, LINA EA 4624, France.

Background: The efficacy and safety of treating elderly patients with colorectal cancer (CRC) is of concern. This study aimed to compare the short- and long-term outcomes of elective laparoscopic vs. open surgery to treat CRC in very elderly patients.

Methods: All patients aged >80 years and who had undergone a colectomy for CRC without metastasis between July 2005 and April 2012 were considered for inclusion. Demographic, clinical, operative, and postoperative data, plus overall and disease-free survival rates, were retrospectively collected and compared between two groups of patients that underwent an open procedure (OP group) or laparoscopy (LG).

Results: 123 patients were enrolled (55 OPG, 68 LG). Median age was similar between the groups (84 vs. 83 years, respectively; NS). Duration of surgery was significantly lower in OPG (170 vs. 200min; p=0.030). Overall mortality at 3 months was 8.3%: it tended to be greater in the OPG (16.5% vs. 1.5%, NS). Morbidity was significantly greater in the OPG compared to the LG (52.7% vs. 27.5%; p=0.021), resulting in significantly longer hospital stay (12 vs. 8 days, respectively; p<0.001). Pathological findings were similar between the two groups. Cumulative overall survival rates at 3 and 5 years were significantly greater after laparoscopy (85% and 72%) compared to open surgery (58.2% and 48%, respectively; p<0.001).

Conclusions: Our study suggests that laparoscopy is safe and could increase overall survival compared to open surgery in elderly patients suffering from CRC.

Summary: This retrospective study compared the short- and longer-term outcomes of patients aged >80 years and undergoing elective laparoscopic or open surgery for CRC between 2005 and 2012.
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http://dx.doi.org/10.1016/j.dld.2016.06.039DOI Listing
January 2017

To Drain or Not to Drain Infraperitoneal Anastomosis After Rectal Excision for Cancer: The GRECCAR 5 Randomized Trial.

Ann Surg 2017 03;265(3):474-480

*Colorectal Unit, Haut Lévêque Hospital, CHU Bordeaux, France †University of Bordeaux, Bordeaux, France ‡Surgical Oncology Department, Montpellier Cancer Institute (ICM), Val d'Aurelle, Montpellier, France §Colorectal Unit, Department of Surgery, Michallon University Hospital, Grenoble, France ¶University Grenoble Alpes, Grenoble, France ||Department of Colorectal Surgery, Beaujon Hospital (AP-HP), Paris VII University, Clichy, France **Department of Surgery, Pontchaillou University Hospital, Rennes, France ††Department of Digestive Surgery, Hospital Center Lyon-Sud, University of Lyon, Lyon, France ‡‡Department of Surgery, Hotel Dieu University Hospital, Nantes, France §§Department of Surgery, Purpan University Hospital, Toulouse, France ¶¶Department of Digestive and Oncological Surgery, Amiens Picardie University Hospital, Amiens, France ||||Inserm Unit, Picardie Jules-Verne University, Amiens, France ***Department of Digestive Surgery, Saint-Joseph Hospital, Paris, France †††Department of Surgery, Bicêtre University Hospital (AP-HP), Le Kremlin-Bicêtre cedex, France ‡‡‡Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, UniversityLille, Lille, France §§§Department of General and Digestive Surgery, University of Aix Marseille, Marseille, France ¶¶¶Department of Digestive and Oncological Surgery, Paoli-Calmettes Institute, Marseille, France ||||||Department of Digestive Surgery, Beauvais Hospital, Beauvais, France ****Department of General and Digestive Surgery, Strasbourg University Hospital, Strasbourg, France ††††Department of Digestive Surgery, University Hospital of Poitiers, Poitiers, France ‡‡‡‡Medical Information Department, USMR, CHU de Bordeaux-Public health pole, Bordeaux, France §§§§INSERM, ISPED, INSERM Center U897-Epidemiology-Biostatistic, Bordeaux, France ¶¶¶¶ISPED, INSERM U897 Center-Epidemiology-Biostatistic, University Bordeaux, Bordeaux, France.

Objective: To assess the effect of pelvic drainage after rectal surgery for cancer.

Background: 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.

Methods: 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.

Results: 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).

Conclusions: 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.
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http://dx.doi.org/10.1097/SLA.0000000000001991DOI Listing
March 2017

The origin and concentration of circulating microparticles differ according to cancer type and evolution: A prospective single-center study.

Int J Cancer 2016 Feb 1;138(4):939-48. Epub 2015 Oct 1.

Aix Marseille Université, INSERM UMR-S1076, VRCM, Marseille, France.

Microparticles are plasma membrane vesicles produced by apoptotic or activated cells and resting cancer cells. The concentration, origin and procoagulant properties of circulating microparticles are reported to differ according to pathological settings (inflammation, cancer and cardiovascular diseases). In case of cancer, different studies have reported a variation in the concentration of circulating microparticles, with an increase in procoagulant and tumor-associated antigen-bearing microparticles. However, the cancer specificity of these results remains unknown. The objective was to establish a specific signature of colorectal and pancreatic cancers (CRC, PC) by characterizing circulating microparticles. Patients presenting with CRC, PC, inflammatory bowel or pancreatic diseases, and healthy subjects, were prospectively included. Circulating microparticles were analyzed by flow cytometry, combining the analysis of Annexin V-positive with characterization of their origin and determination of their procoagulant activities. We included 85, 36, 15, 18 and 20 patients presenting with CRC, PC, inflammatory bowel or pancreatic diseases, and healthy subjects, respectively. Here, we depict a specific signature, which differed between CRC, PC, associated inflammatory bowel and pancreatic diseases and healthy subjects. Furthermore, in patients with remission, this signature returned to the levels observed in associated inflammatory or healthy patients. Our results indicate that circulating microparticles differ depending on the evolution of a cancer. The analysis of the circulating microparticles reveals the specificity of the signature and can be used as a new complex biomarker reflecting the evolution of the disease.
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http://dx.doi.org/10.1002/ijc.29837DOI Listing
February 2016

Impact of venous thromboembolism on the natural history of pancreatic adenocarcinoma.

Hepatobiliary Pancreat Dis Int 2015 Aug;14(4):436-42

Departments of Digestive Surgery, Timone Hospital, Aix-Marseille University, Marseille, France; Atelier Provencale d'Ecriture Medicale, Faculte de Medecine de Marseille; Groupe Francophone Thrombose et Cancer, Hopital ST Louis, 1 avenue Claude Vellefaux, Paris, France. [email protected] mail.ap-hm.fr.

Background: Few studies have analyzed the effect of venous thromboembolism (VTE) events on the prognosis of pancreatic cancer, but their results were conflicting. The present study was undertaken to determine the effect of VTE on pancreatic adenocarcinoma (PA) outcomes.

Methods: All consecutive patients diagnosed with PA from May 2004 to January 2012 in a single oncology center were retrospectively studied. Clinical, radiological and histological data at time of diagnosis or within the first 3 months after surgery, including the presence (+) or absence (-) of VTE were collected. VTE was defined as radiological evidence of either pulmonary embolism (PE), deep venous thrombosis without infection or catheter-related thrombosis. PA with and without PE was compared for survival using the Kaplan-Meier method to estimate overall survival.

Results: Among 162 PA patients with a median follow-up of 15 (3-92) months after diagnosis, 28 demonstrated VTE (+). PA patients with and without PE were similar for age, American Society of Anesthesiologist score, body mass index, and history of treatment. The distribution of cancer stages was similar between the two groups VTE (+) and VTE (-). The median duration of survival was significantly worse in the VTE (+) group vs VTE (-) (12 vs 18 months, P=0.010). In multivariate analysis, the presence of VTE and surgical treatment were independent prognostic factors for overall survival.

Conclusion: VTE (+) at time of diagnosis or within the first 3 months after surgery during treatment is an independent factor of poor prognosis in PA.
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http://dx.doi.org/10.1016/s1499-3872(15)60397-6DOI Listing
August 2015

A retrospective comparison of older and younger adults undergoing early laparoscopic cholecystectomy for mild to moderate calculous cholecystitis.

J Am Geriatr Soc 2015 May 6;63(5):1010-6. Epub 2015 May 6.

Department of Digestive Surgery, Amiens University Hospital, Amiens, France.

Objectives: To compare the demographic characteristics and intra- and postoperative outcomes in elderly adults (≥75) with those of younger adults undergoing early (<5 days after onset of complaints) cholecystectomy.

Design: Retrospective analysis from May 2010 to August 2012.

Setting: Randomized, multicenter, clinical trial (ABCAL Study, NCT01015417).

Participants: Individuals with mild or moderate acute calculous cholecystitis (ACC) according to the Tokyo Guidelines (N=414; n=78 aged 75-94, median 82; n=336 aged 18-74, median 49).

Measurements: Demographic characteristics and pre-, intra-, and postoperative data.

Results: The elderly group was more likely to have an American Society of Anesthesiologists score of 3 or greater (62% vs 23%, P<.001), higher serum creatinine (103 vs 74 μmol/L, P<.001), and more-severe ACC (moderate ACC (62% vs 50%, P=.05), gangrenous cholecystitis (38% vs 15%, P=.001)) on preoperative imaging and confirmed intraoperatively. Ulcerated mucosa (76% vs 61%, P=.001) was significantly more frequent in the elderly group. Operative time, postoperative mortality, and postoperative infectious (18% vs 14%, P=.35) and noninfectious (9% vs 3%, P=.80) complications were similar between the two groups. Median length of stay (7.0 vs 5.0 days, P=.54) and readmission rate (15% vs 4%, P=.07) were not significantly higher in the elderly group. No significant difference was observed for the subgroup of participants aged 80 and older.

Conclusion: In this randomized trial that included a selected sample of older adults, there was no difference in major outcomes between elderly adults and their younger counterparts after early cholecystectomy. The findings are limited because important geriatric outcomes such as delirium and functional decline were not examined.
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http://dx.doi.org/10.1111/jgs.13330DOI Listing
May 2015

Further characterization of HDAC and SIRT gene expression patterns in pancreatic cancer and their relation to disease outcome.

PLoS One 2014 2;9(9):e108520. Epub 2014 Oct 2.

Aix-Marseille University, CRO2, UMR_S 911, Marseille, France; INSERM UMR 911, Marseille, France.

Ductal adenocarcinoma of the pancreas is ranking 4 for patient' death from malignant disease in Western countries, with no satisfactory treatment. We re-examined more precisely the histone deacetylases (HDAC) and Sirtuin (SIRT) gene expression patterns in pancreatic cancer with more pancreatic tumors and normal tissues. We also examined the possible relationship between HDAC gene expression levels and long term disease outcome. Moreover, we have evaluated by using an in vitro model system of human pancreatic tumor cell line whether HDAC7 knockdown may affect the cell behavior. We analyzed 29 pancreatic adenocarcinoma (PA), 9 chronic pancreatitis (CP), 8 benign pancreatic (BP) and 11 normal pancreatic tissues. Concerning pancreatic adenocarcinoma, we were able to collect biopsies at the tumor periphery. To assess the possible involvement of HDAC7 in cell proliferation capacity, we have generated recombinant human Panc-1 tumor which underexpressed or overexpressed HDAC7. The expression of HDAC1,2,3,4,7 and Nur77 increased in PA samples at levels significantly higher than those observed in the CP group (p = 0.0160; 0.0114; 0.0227; 0.0440; 0.0136; 0.0004, respectively). The expression of HDAC7, was significantly greater in the PA compared with BP tissue samples (p = 0.05). Mean mRNA transcription levels of PA for HDAC7 and HDAC2 were higher when compared to their counterpart biopsies taken at the tumor periphery (p = 0.0346, 0.0053, respectively). Moreover, the data obtained using confocal microscopy and a quantitative method of immunofluorescence staining strongly support the HDAC7 overexpression in PA surgical specimens. The number of deaths and recurrences at the end of follow up were significantly greater in patients with overexpression of HDAC7. Interestingly, the rate of growth was significantly reduced in the case of cell carrying shRNA construct targeting HDAC7 encoding gene when compared to the parental Panc-1 tumor cells (p = 0.0015) at 48 h and 96 h (p = 0.0021). This study strongly support the notion that HDAC7play a role in pancreatic adenocarcinoma progression.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0108520PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4183483PMC
June 2015

Effect of postoperative antibiotic administration on postoperative infection following cholecystectomy for acute calculous cholecystitis: a randomized clinical trial.

JAMA 2014 Jul;312(2):145-54

Division of Digestive Disease, Paris Lariboisière Hospital, Paris, France.

Importance: Ninety percent of cases of acute calculous cholecystitis are of mild (grade I) or moderate (grade II) severity. Although the preoperative and intraoperative antibiotic management of acute calculous cholecystitis has been standardized, few data exist on the utility of postoperative antibiotic treatment.

Objective: To determine the effect of postoperative amoxicillin plus clavulanic acid on infection rates after cholecystectomy.

Design, Setting, And Patients: A total of 414 patients treated at 17 medical centers for grade I or II acute calculous cholecystitis and who received 2 g of amoxicillin plus clavulanic acid 3 times a day while in the hospital before and once at the time of surgery were randomized after surgery to an open-label, noninferiority, randomized clinical trial between May 2010 and August 2012.

Interventions: After surgery, no antibiotics or continue with the preoperative antibiotic regimen 3 times daily for 5 days.

Main Outcomes And Measures: The proportion of postoperative surgical site or distant infections recorded before or at the 4-week follow-up visit.

Results: An imputed intention-to-treat analysis of 414 patients showed that the postoperative infection rates were 17% (35 of 207) in the nontreatment group and 15% (31 of 207) in the antibiotic group (absolute difference, 1.93%; 95% CI, -8.98% to 5.12%). In the per-protocol analysis, which involved 338 patients, the corresponding rates were both 13% (absolute difference, 0.3%; 95% CI, -5.0% to 6.3%). Based on a noninferiority margin of 11%, the lack of postoperative antibiotic treatment was not associated with worse outcomes than antibiotic treatment. Bile cultures showed that 60.9% were pathogen free. Both groups had similar Clavien complication severity outcomes: 195 patients (94.2%) in the nontreatment group had a score of 0 to I and 2 patients (0.97%) had a score of III to V, and 182 patients (87.8%) in the antibiotic group had a score of 0 to I and 4 patients (1.93%) had a score of III to V.

Conclusions And Relevance: Among patients with mild or moderate calculous cholecystitis who received preoperative and intraoperative antibiotics, lack of postoperative treatment with amoxicillin plus clavulanic acid did not result in a greater incidence of postoperative infections.

Trial Registration: clinicaltrials.gov Identifier: NCT01015417.
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http://dx.doi.org/10.1001/jama.2014.7586DOI Listing
July 2014

Pelvic radiation disease management by hyperbaric oxygen therapy: prospective study of 44 patients.

Gastroenterol Res Pract 2014 27;2014:108073. Epub 2014 Jan 27.

Aix-Marseille University, UMR 911, Campus Santé Timone, 13005 Marseille, France ; Hyperbaric Medicine, Sainte Marguerite Hospital, Aix-Marseille University, UMR MD2, 13385 Marseille, France.

Pelvic radiation disease (PRD) occurs in 2-11% of patients undergoing pelvic radiation for urologic and gynecologic malignancies. Hyperbaric oxygen therapy (HBOT) has previously been described as a noninvasive therapeutic option for the treatment of PRD. the purpose of study was to analyze prospectively the results of HBOT in 44 consecutive patients with PRD who were resistant to conventional oral or topical treatments. Material and Methods. The median age of the cohort was 65.7 years (39-85). Twenty-seven percent of patients required blood transfusion (n = 12). The median of delay between radiotherapy and HBOT was 26 months (3-175). We evaluated the results of HBOT, using SOMA-LENT Scale. Results. SOMA-LENT score was decreased in 59% of patient. The median of SOMA-LENT score before HBOT was significantly higher, being equal to 14 (0-36), than after HBOT with the SOMA-LENT score of 12 (0-38) (P = 0.003). Tenesmus (P = 0.02), bleeding (P = 0.0001), and ulceration (P = 0.001) significantly decreased after HBOT. Regarding patients with colostomy, 33% (n = 4) benefited from colostomies closure. HBOT was generally well tolerated. Only one patient stopped precociously due to transient myopia. Conclusion. This study is in favor of the interest of HBOT in pelvic radiation disease treatment (PRD).
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http://dx.doi.org/10.1155/2014/108073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3922018PMC
March 2014

Assistance for the prescription of nutritional support must be required in nonexperienced nutritional teams.

J Nutr Metab 2013 17;2013:450469. Epub 2013 Dec 17.

Department of Digestive Surgery, Timone Hospital, 13385 Marseille, France ; Aix Marseille University, UMR 911, Campus Santé Timone, 13385 Marseille, France.

The aim of the study was to determine the current practices of nutritional support among hospitalized patients in nonspecialized hospital departments. Materials and Methods. During an observation period of 2 months, a surgeon and a gastroenterologist designated in each of the two departments concerned, not "specialized" in nutritional assistance, have treated patients in which nutritional support seemed necessary. Assessing the degree of malnutrition of the patient, the therapeutic decision and the type of product prescribed by the doctors were secondarily compared to the proposals of a structured computer program according to the criteria and standards established by the institutions currently recognized. Results. The study included 120 patients bearing a surgical disease in 86.7% of cases and 10% of medical cases. 50% of the patients had cancer. Nutritional status was correctly evaluated in 38.3% by the initial doctors' diagnosis-consistent with the software's evaluation. The strategy of nutrition was concordant with the proposals of the software in 79.2% of cases. Conclusions. Despite an erroneous assessment of the nutritional status in more than two-thirds of cases the strategy of nutritional management was correct in 80% of cases. Malnutrition and its consequences can be prevented in nonexperienced nutritional teams by adequate nutritional support strategies coming from modern techniques including computerized programs.
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http://dx.doi.org/10.1155/2013/450469DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3877633PMC
February 2014

Characteristics and natural history of patients with colorectal cancer complicated by infectious endocarditis. Case control study of 25 patients.

Anticancer Res 2014 Jan;34(1):349-53

Service de Chirurgie Digestive et viscérale, Pôle DACCORD, Hopital Timone .264 rue saint Pierre, 13385 Marseille, France.

Unlabelled: Association between streptococcal endocarditis and gastrointestinal disease has been well-documented in the literature. However oncological impact of this complicated presentation has not yet been reported. We have conducted to our knowledgethe first case-control study on this subject.

Patients And Methods: Two groups of five patients with colorectal cancer and either active endocarditis (CRC E+), or without endocarditis (CRC, n=20) were matched 1:4 for age, sex, and location of colorectal tumor.

Results: All 25 patients were male, with a median age of 63 (range: 53-85) years. Twenty (80%) had colon cancer and 5 (20%) rectal cancer. There was no post-operative mortality in this population. The overall morbidity was 28% (n=7). The overall 3-year survival and recurrence rates were similar in both groups 80% and 95%; 0% and 30% for group CRC E+ and CRC (p=0.4603).

Conclusion: This is the first case-control study demonstrating that during the first two years of follow-up, occurrence of endocarditis did not alter the prognosis of patients with CRC.
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January 2014
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