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Treton X.,Pole des Maladies de lAppareil Digestif PMAD
Colon and Rectum

During the last 15 years, numerous progresses in the field of IBD were made, and the practice has evolved significantly. Treatment of IBD has been revolutionized by the advent of anti-TNF, based on their ability to achieve mucosal healing, in contrast with previous treatments. Moreover, the learning of their use, of their side effects and of the way to develop new strategies in combination, has also changed our practices. At the same time, treatment goals have become more ambitious, with the need to obtain, when possible and reasonable, mucosal control of the disease. This was possible by the development of endoscopical techniques but also with non-invasive tools like MRI and fecal calprotectin. Finally, new treatments arrive or will soon be available, such as anti-integrin, anti-JAK kinases and cell therapy. This will need to prioritize their use, and to identify new individual factors of responses to develop a personalized medicine for IBD. © 2015, Springer-Verlag France. Source

Gaujoux S.,Pole des Maladies de lAppareil Digestif PMAD | Cortes A.,Pole des Maladies de lAppareil Digestif PMAD | Couvelard A.,Pole des Maladies de lAppareil Digestif PMAD | Noullet S.,Pole des Maladies de lAppareil Digestif PMAD | And 6 more authors.

Background: Pancreatic fistula (PF) after pancreatoduodenectomy (PD) remains a challenging problem. The only commonly accepted risk factor is the soft consistency of the pancreatic remnant. Methods: In all, 100 consecutive patients underwent PD. All data, including commonly accepted risk factors for PF and PF defined according to the International Study Group of Pancreatic Fistula, were collected prospectively. On the pancreatic margin, a score of fibrosis and a score of fatty infiltration were assessed by a pathologist blinded to the postoperative course. Results: PF occurred in 31% of patients. In univariate analysis, male sex, age greater than 58 years, body mass index (BMI) ≥25 kg/m2, pre-operative high blood pressure, operation for nonintraductal papillary and mucinous neoplasm (IPMN) disease and for ampullary carcinoma, operative time, blood loss, soft consistency of the pancreatic remnant, absence of pancreatic fibrosis, and presence of fatty infiltration of the pancreas were associated with a greater risk of PF. In a multivariate analysis, only BMI ≥25kg/m2, absence of pancreatic fibrosis, and presence of fatty pancreas were significant predictors of PF. A score based on the number of risk factors present divided the patient population into 4 subgroups carrying a risk of PF that ranged from 7% (no risk factor) to 78% (3 risk factors) and from 0% to 81%, taking into account only symptomatic PF (grade B and C). Conclusion: The presence of an increased BMI, the presence of fatty pancreas, and the absence of pancreatic fibrosis as risk factors of PF allows a more precise and objective prediction of PF than the consistency of pancreatic remnant alone. A predictive score based on these 3 factors could help to tailor preventive measures. © 2010. Source

Buc E.,Pole des Maladies de lAppareil Digestif PMAD | Couvelard A.,AP HP | Kwiatkowski F.,Center Jean Perrin | Dokmak S.,Pole des Maladies de lAppareil Digestif PMAD | And 4 more authors.
European Journal of Surgical Oncology

Background: Lymph node (LN) invasion in pancreatic ductal adenocarcinoma (PDAC) is the most important prognostic factor after surgical resection. The mechanisms of LN invasion include lymphatic spreading and/or direct extension from the main tumor. However, few studies have assessed the impact of these different patterns of invasion on prognosis. Patients and methods: Pathologic reports of pancreatic resections for PDAC from 1997 to 2007 were retrospectively analyzed. The mode of LN invasion was defined as follows: standard lymphatic metastases (S), contiguous from the main tumor (C) and standard with extracapsular invasion (EI). Clinical outcomes were compared according to the mode of invasion and the number of invaded LN. Results: 306 patients were reviewed. Median age at resection was 61 years (range, 34-81). Eighty seven patients were N-(28.9%) and 214 were N+ (71.1%). Of the N+ patients, 195 (91.1%) were S+, 35 (16.3%) were C+, and 24 (12.3% of the S+ patients) were EI+. Median survival in N+ patients was lower than in N-patients (29 vs. 57 months, p < 0.001). In patients without standard involvement, C+ patients (n = 19) had worse survival than C-patients (n = 47) (34 vs. 57 months, p = 0.037). In S+ patients, C status was correlated with prognosis when the number of LN S+ was <2 (p = 0.07). EI status had no influence on prognosis. On multivariate analysis, only perineural invasion (p = 0.02) and LN ratio (p = 0.042) were independent prognostic factors. Conclusion: Direct invasion of LN by the tumor is predictive of reduced survival, but has little impact compared to standard LN involvement and perineural invasion. © 2014 Elsevier Ltd. All rights reserved. Source

Maggiori L.,Pole des Maladies de lAppareil Digestif PMAD | Bretagnol F.,Pole des Maladies de lAppareil Digestif PMAD | Aslam M.I.,Pole des Maladies de lAppareil Digestif PMAD | Aslam M.I.,University of Leicester | And 4 more authors.
Surgery (United States)

Background A pathologic complete response (pCR) can be observed in up to 25% of patients after preoperative chemoradiotherapy for rectal cancer and is associated with an improved long-term prognosis. However, few data are available regarding the effect of pCR on postoperative morbidity. This study aimed to assess the impact of the pCR on postoperative outcomes after laparoscopic total mesorectal excision (TME). Methods A prospectively maintained database (2006-2011) was reviewed for all consecutive patients (n = 143) undergoing laparoscopic TME for mid or low rectal cancer after neoadjuvant chemoradiotherapy. Postoperative data were compared for pCR-group and non-pCR-group. A pCR was defined as the absence of gross and microscopic tumor in the specimen, irrespective of the nodal status (ypT0). Results Thirty-three patients (23%) had a pCR. Median operating time was greatly shorter in the pCR-group (230 minutes, 180-360), compared with the non-pCR-group (240 minutes, 130-420, P =.02). Lymph node involvement was noted for 12% of the patients in the pCR-group and 33% of the patients in the non-pCR-group (P =.91). Clavien Dindo grade 3 and 4 complications (6% vs 22%, P =.04), infection related morbidity (47% vs 76%, P =.04), and clinical anastomotic leakage rates (9% vs 29%, P =.02) were lesser in the pCR group compared with the non-pCR group. Mean duration of hospital stay was lesser in the pCR-group (9 vs 12 days, P =.01). Conclusion This study showed that Clavien Dindo grade 3 and 4 complications, including anastomosis leakage, and infection related complications rates were lesser in patients with pathologic complete response after RCT and laparoscopic TME for rectal cancer. © 2014 Mosby, Inc. All rights reserved. Source

Maggiori L.,Pole des Maladies de lAppareil Digestif PMAD | Bretagnol F.,Pole des Maladies de lAppareil Digestif PMAD | Lefevre J.H.,Pole des Maladies de lAppareil Digestif PMAD | Ferron M.,Pole des Maladies de lAppareil Digestif PMAD | And 2 more authors.
Colorectal Disease

Aim Anastomotic leakage (AL) after sphincter-saving resection (SSR) for rectal cancer can result in a definitive stoma (DS). The aim of the study was to assess risk factors for DS after AL-complicating SSR. Method Between 1997 and 2007, 200 patients underwent SSR for rectal cancer. AL occurred in 20.5% (41/200) [symptomatic 13.5% (n=27), asymptomatic 7% (n=14)]. Possible risk factors for DS after AL were analysed. Results Management of AL consisted in no treatment (n=14), medical treatment (n=6), local drainage (n=10) and abdominal reoperation (n=11). After a median follow-up of 38months, the overall rate of DS was 3% (n=6): 0% for asymptomatic vs 22% after symptomatic AL (P=0.061). After reoperation, the risk of DS was 13% when the anastomosis was preserved vs 100% after Hartmann's procedure (P=0.007). Risk factors of DS after AL included obesity, age over 65, American Society of Anesthesiologists (ASA) score >2 and abdominal reoperation for AL. Conclusion The risk of DS after SSR for cancer is low (3%) but rises to 22% after symptomatic AL. This risk depends on the surgical treatment for AL and is up to 100% if a Hartmann's procedure is performed. © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland. Source

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