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SMAD4 is inactivated in 50-55% of pancreatic ductal adenocarcinomas (PDACs). SMAD4 loss of expression has been described as a negative prognostic factor in PDAC associated with an increased rate of metastasis and resistance to therapy. However, the impact of SMAD4 inactivation in patients receiving neoadjuvant therapy (NAT) is not well characterized. The aim of our study was to investigate whether SMAD4 status is a prognostic and predictive factor in patients receiving NAT., SCOPUS: ar.j, info:eu-repo/semantics/published

Multidisciplinary team (MDT) meetings aim to optimize patient management. We evaluated the impact of MDT discussions on the management and diagnosis of focal pancreatic lesions in a single tertiary center., SCOPUS: ar.j, info:eu-repo/semantics/published

Sleeve gastrectomy (SG) is the most frequently performed bariatric procedure in the world. Our purpose was to evaluate the percentage of excess weight loss (%EWL), resolution of obesity-related comorbidities after SG, and identify predictive factors of weight loss failure. A prospective cohort study of adults who underwent SG during 2014 in 7 Belgian-French centers. Their demographic, preoperative, and postoperative data were prospectively collected and analyzed statistically. Overall, 529 patients underwent SG, with a mean preoperative weight and body mass index BMI) of 118.9 ± 19.9 kg and 42.9 ± 5.5 kg/m, respectively. Body mass index significantly decreased to 32.2 kg/m at 5 years ( < .001). The mean %EWL was 63.6% at 5 years. A significant reduction in dyslipidemia (28.0%-18.2%), obstructive sleep apnea (OSAS) (34.6%-25.1%), and arterial hypertension (HTN) (30.4%-21.5%) was observed after 5 years, but not for diabetes and gastroesophageal reflux disease (GERD). At multivariate analysis, age >50 years old, BMI >50 kg/m, and previous laparoscopic adjustable gastric banding (LAGB) remained independent predictors of weight loss failure. Five years after SG, weight loss was satisfactory; the reduction of comorbidities was significant for dyslipidemia, OSAS, and HTN, but not diabetes and GERD. Age >50 years old, BMI >50 kg/m, and previous LAGB were independent predictors of weight loss failure.

BACKGROUND: Adverse economic conditions often prevent the widespread implementation of modern surgical techniques in third world countries such as in Sub-Sahara Africa. AIM OF THE STUDY: To demonstrate that a modern technique (laparoscopic totally extraperitoneal inguinal hernioplasty [TEP]) can safely be performed at significantly lower cost using inexpensive mesh material. SETTINGS: Douala University Hospital Gynecology, Obstetrics and Pediatrics and two affiliated centers, Ayos Regional Hospital and Edéa Regional Hospital in Cameroon. PATIENTS AND METHODS: Prospective randomized controlled trial (RCT) of consecutive adult patients presenting with primary inguinal hernia treated by TEP, comparing implantation of sterilized mosquito mesh (MM) with conventional polypropylene mesh (CM). Primary endpoints were peroperative, early and midterm postoperative complications and hernia recurrence at 30 months. RESULTS: Sixty-two patients (48 males) were randomized to MM (n = 32) or CM (n = 30). Groups were similar in age distribution and occupational features. Peroperative and early outcomes differed in terms of conversion rate (2/32 MM) due to external (electrical power supply) factors and mesh removal for early obstruction (1/30 CM). No outcome differences, including no recurrences, were noted after a median follow-up of 21 months. CONCLUSION: In this RCT with medium-term follow-up, TEP performed with MM appears not inferior to CM.

Background Opioid-free anesthesia (OFA) is associated with significantly reduced cumulative postoperative morphine consumption in comparison with opioid-based anesthesia (OBA). Whether OFA is feasible and may improve outcomes in pancreatic surgery remains unclear. Methods Perioperative data from 77 consecutive patients who underwent pancreatic resection were included and retrospectively reviewed. Patients received either an OBA with intraoperative remifentanil ( n = 42) or an OFA ( n = 35). OFA included a combination of continuous infusions of dexmedetomidine, lidocaine, and esketamine. In OBA, patients also received a single bolus of intrathecal morphine. All patients received intraoperative propofol, sevoflurane, dexamethasone, diclofenac, neuromuscular blockade. Postoperative pain management was achieved by continuous wound infiltration and patient-controlled morphine. The primary outcome was postoperative pain (Numerical Rating Scale, NRS). Opioid consumption within 48 h after extubation, length of stay, adverse events within 90 days, and 30-day mortality were included as secondary outcomes. Episodes of bradycardia and hypotension requiring rescue medication were considered as safety outcomes. Results Compared to OBA, NRS (3 [2–4] vs 0 [0–2], P < 0.001) and opioid consumption (36 [24–52] vs 10 [2–24], P = 0.005) were both less in the OFA group. Length of stay was shorter by 4 days with OFA (14 [7–46] vs 10 [6–16], P < 0.001). OFA ( P = 0.03), with postoperative pancreatic fistula ( P = 0.0002) and delayed gastric emptying ( P < 0.0001) were identified as only independent factors for length of stay. The comprehensive complication index (CCI) was the lowest with OFA (24.9 ± 25.5 vs 14.1 ± 23.4, P = 0.03). There were no differences in demographics, operative time, blood loss, bradycardia, vasopressors administration or time to extubation among groups. Conclusions In this series, OFA during pancreatic resection is feasible and independently associa, SCOPUS: ar.j, SCOPUS: ar.j, info:eu-repo/semantics/published

Radical cystectomy (RC) is the gold standard treatment for muscle invasive bladder cancer (MIBC) and high-risk non-muscle invasive bladder cancer (NMIBC). Nonetheless, the procedure is a highly morbid surgery, usually performed in frail patients. As such, overall complication rate is reported as high as 75% and major complications are encountered in 10- 20% of patients. Moreover, peri-operative mortality remains estimated at 2-3% even in high- volume expert centers. During the last ten years, surgical pioneers have adopted minimally invasive techniques such as laparoscopic and robotics to RC in the effort to reduce surgical morbidity.First, I have worked deeply in the analysis of oncologic and functional results of pure laparoscopic RC. I have also raised awareness on possible oncologic failures after minimally invasive RC, which has been a hot topic in the urologic community during the last years.Then, following the widespread adoption of the robotic platform across European centers, I have analyzed and studied the potential enhancements of applying robotic surgery to radical cystectomy.The hypothesis of this PhD thesis is that robotic cystectomy with intracorporeal urinary diversion can yield significant advantages for urothelial cancer patients and that current surgical practice has not unlocked completely the potential of the procedure. My research has thus focused on optimizing the results of robotic cystectomy with intracorporeal urinary diversion and exploring strategies to enhance this procedure, which is key in the management of bladder cancer.I have explored novel classification scores for post-operative complications, analyzed in depth hemorrhagic and ischemic complications with special focus on antiplatelet management before and after radical cystectomy, evaluated the implementation of Enhanced Recovery After Surgery (ERAS) protocols. I have then completed my research by analyzing the costs of robotic-assisted radical cystectomy, a topic of great interes, Doctorat en Sciences médicales (Médecine), info:eu-repo/semantics/nonPublished

Introduction: Patients undergoing weight loss surgery do not improve their aerobic capacity or peak oxygen uptake (VO2peak) after bariatric surgery and some still complain about asthenia and/or breathlessness. We investigated the hypothesis that a post-surgery muscular limitation could impact the ventilatory response to exercise by evaluating the post-surgery changes in muscle mass, strength, and muscular aerobic capacity, measured by the first ventilatory threshold (VT). Methods: Thirteen patients with obesity were referred to our university exercise laboratory before and 6 months after bariatric surgery and were matched by sex, age, and height to healthy subjects with normal weight. All subjects underwent a clinical examination, blood sampling, and body composition assessment by dual-energy X-ray absorptiometry, respiratory and limb muscle strength assessments, and cardiopulmonary exercise testing on a cyclo-ergometer. Results: Bariatric surgery resulted in a loss of 34% fat mass, 43% visceral adipose tissue, and 12% lean mass (LM) (p < 0.001). Absolute handgrip, quadriceps, or respiratory muscle strength remained unaffected, while quadriceps/handgrip strength relative to LM increased (p < 0.05). Absolute VO2peak or VO2peak/LM did not improve and the first VT was decreased after surgery (1.4 ± 0.3 vs. 1.1 ± 0.4 L min-1, p < 0.05) and correlated to the exercising LM (LM legs) (R = 0.84, p < 0.001). Conclusions: Although bariatric surgery has numerous beneficial effects, absolute VO2peak does not improve and the weight loss-induced LM reduction is associated to an altered muscular aerobic capacity, as reflected by an early VT triggering early exercise hyperventilation., IF 2021 (update 2022) :4.807, SCOPUS: ar.j, info:eu-repo/semantics/published

BACKGROUND: In Sub-Saharan Africa (SSA), economic conditions often do not always permit the use of modern surgical techniques, especially for hernia treatment. Aim of the study: To demonstrate that a modern technique such as Laparoscopic Total Extraperitoneal inguinal hernioplasty (TEP) can be performed at a significantly lower cost thanks to the use of a less expensive mesh material. SETTINGS: The study was performed in Douala at the Gynaecology-Obstetric and Paediatric University Hospital and at governmental Regional Hospitals of Ayos and Edéa in Cameroon. MATERIAL AND METHODS: Prospective, randomised, double-blind, controlled trial (RCT) including consecutive adult patients presenting with primary inguinal hernia treated by TEP, with implantation of either sterilised mosquito net mesh (MNM) or conventional polypropylene mesh (CPM). RESULTS: 62 patients were enrolled; randomization allocated 32 to MNM and 30 to CPM. Both groups were comparable for age and professional activities. Significant perioperative differences pertained to conversion rate (2/32 MNM), due to external (electrical power) factors and mesh removal for early obstruction (1/30 CPM). Hospital stay was less than 2 days in both groups. All patients resumed their activities after 3 weeks. Costs were significantly lower in the MNM group. No recurrences were noted with a follow-up of median 21(12-30) months. CONCLUSION: This RCT shows that TEP with MNM is feasible, cost-effective with good outcomes in SSA hospital setting.

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SCOPUS: le.j, info:eu-repo/semantics/published

Epidermoid cysts are rare lesions that can occur anywhere in the body. They are associated with elevated serum levels of CA 19-9. The spleen represents the most common site of intra-abdominal localisation. Only two cases of diaphragmatic epidermoid cyst are reported in the literature. We present the case of a 61-year-old woman with a small suprasplenic subdiaphragmatic cyst discovered during the investigation of left flank pain. The establishment of an adequate diagnosis was challenging due to the difficulty in specifying the exact localisation of the cyst, the extremely elevated CA 19-9 level of 19,000 and the high uptake on 18-fluoro-2-deoxy-D-glucose positron emission tomography. The definitive diagnosis followed complete surgical excision. Intra-abdominal epidermoid cysts are usually discovered incidentally on imaging for another reason. The cyst is lined by squamous epithelium responsible for the secretion of CA 19-9. The elevation of serum CA 19-9 is due to small rupture or increased intraluminal pressure followed by diffusion to the bloodstream. Surgery with en-bloc resection represents the optimal treatment to avoid any risk of recurrence. The definitive diagnosis is established by demonstrating positive immunohistopathological staining of epithelial cell to CA 19.9., SCOPUS: ar.j, info:eu-repo/semantics/published

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OBJECTIVES: Postoperative complications after Laparoscopic sleeve gastrectomy (LSG) can dramatically compromise patient's outcome. The aim of this study is to analyze the per- and postoperative short-term outcomes after LSG and to assess predictive risk factors of complications. METHODS: The study group consisted of 790 patients (610 women and 180 men) who underwent LSG In 2014. All interventions were performed by 18 experienced surgeons members of the Club Coelio. Data about preoperative work-up, surgical techniques, 30-days postoperative morbidity and mortality were collected. Endpoints were perioperative morbidity and mortality and assessment of potential risk factors for complications. RESULTS: Mean age and body mass index were respectively 39 years and 41.5kg/m2. Ninety-one patients (11.5%) had previous bariatric surgery. Morbidity rate was 4.7% (37/790) including 16 leaks (2.0%) and 9 bleedings (1.1%) and no deaths. Risk factors for leak were: previous adjustable banding (p = .0051), with no difference between removal of the banding and LSG in 1 or 2 steps, and type of endostapler (p = .0129). CONCLUSIONS: Leakage after Sleeve was rare but still observed even in experienced hands. The leak rate is particularly high when LSG is performed after adjustable gastric banding removal.

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Background: The type of fluid and volume regimen given intraoperatively both can impact patient outcome after major surgery. This two-arm, parallel, randomized controlled, double-blind, bi-center superiority study tested the hypothesis that when using closed-loop assisted goal-directed fluid therapy, balanced colloids are associated with fewer postoperative complications compared to balanced crystalloids in patients having major elective abdominal surgery. Methods: One hundred and sixty patients were enrolled in the protocol. All patients had maintenance-balanced crystalloid administration of 3 ml · kg-1 · h-1. A closed-loop system delivered additional 100-ml fluid boluses (patients were randomized to receive either a balanced-crystalloid or colloid solution) according to a predefined goal-directed strategy, using a stroke volume and stroke volume variation monitor. All patients were included in the analysis. The primary outcome was the Post-Operative Morbidity Survey score, a nine-domain scale, at day 2 postsurgery. Secondary outcomes included all postoperative complications. Results: Patients randomized in the colloid group had a lower Post-Operative Morbidity Survey score (median [interquartile range] of 2 [1 to 3] vs. 3 [1 to 4], difference -1 [95% CI, -1 to 0]; P < 0.001) and a lower incidence of postoperative complications. Total volume of fluid administered intraoperatively and net fluid balance were significantly lower in the colloid group. Conclusions: Under our study conditions, a colloid-based goal-directed fluid therapy was associated with fewer postoperative complications than a crystalloid one. This beneficial effect may be related to a lower intraoperative fluid balance when a balanced colloid was used. However, given the study design, the mechanism for the difference cannot be determined with certainty., SCOPUS: ar.j, info:eu-repo/semantics/published

Objectives: Postoperative complications after Laparoscopic sleeve gastrectomy (LSG) can dramatically compromise patient’s outcome. The aim of this study is to analyze the per- and postoperative short-term outcomes after LSG and to assess predictive risk factors of complications. Methods: The study group consisted of 790 patients (610 women and 180 men) who underwent LSG In 2014. All interventions were performed by 18 experienced surgeons members of the Club Coelio. Data about preoperative work-up, surgical techniques, 30-days postoperative morbidity and mortality were collected. Endpoints were perioperative morbidity and mortality and assessment of potential risk factors for complications. Results: Mean age and body mass index were respectively 39 years and 41.5kg/m2. Ninety-one patients (11.5%) had previous bariatric surgery. Morbidity rate was 4.7% (37/790) including 16 leaks (2.0%) and 9 bleedings (1.1%) and no deaths. Risk factors for leak were: previous adjustable banding (p =.0051), with no difference between removal of the banding and LSG in 1 or 2 steps, and type of endostapler (p =.0129). Conclusions: Leakage after Sleeve was rare but still observed even in experienced hands. The leak rate is particularly high when LSG is performed after adjustable gastric banding removal., SCOPUS: ar.j, info:eu-repo/semantics/published

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The prevalence of post-bariatric complications and post-bariatric leaks has dramatically increased over the last two decades, in line with the pandemic of morbid obesity and the growing number of bariatric surgeries. For bariatric leaks, re-operation with drainage, and possibly an attempt at surgical closure, has, for a long time, been considered as the only possible treatment.In the early 2000s, our team started to be involved in post bariatric complications management and, with the experience we acquired in other diseases associated with upper gastrointestinal leakages, endotherapy became logically a good theoretical option to treat these leaks. It offers a potentially less invasive alternative to an unsatisfactory surgical management.Insertion of a self-expandable stent to cover the leak and facilitate its closure was our initial treatment strategy. Our retrospectives studies in this field, in addition to demonstrating good results, helped to identify major clinical factors associated with treatment success, such as early endoscopic management after leakage diagnosis. We promoted the use of partially covered stents which helps to reduce the risk of migration, probably increases watertightness, and can be efficiently extracted after the insertion of a fully covered stent.However, post bariatric leaks is a serious and difficult clinical situation and we experienced disappointing results with stent treatment alone in several patients. This led us to develop complementary techniques, such as fistula plug insertion or internal drainage with double pig tail stents, which provided additional positive results. Internal drainage even appears to be effective as an isolated strategy in selected patients.The present work illustrates the evolution of this new clinical modality and demonstrates, based on our published results, how endotherapy has become a first-line option that now plays a pivotal role in the multimodal approach to post-bariatric leakage. We show that, in the, Doctorat en Sciences médicales (Médecine), info:eu-repo/semantics/nonPublished

Introduction: There are very few case reports of metastasis on a mesh prosthesis following laparoscopic hernia repair in the literature and its incidence is completely unknown. Case report: A 76-year-old male patient presented in December 2013 with a suspicious malignant lesion of the pancreatic tail on the MRI. He was also complaining of a painful mass in the right para-rectal area. An exploratory laparoscopy performed in December 2013 revealed microscopic whitish peritoneal implants in the left hypochondrium and a massive metastasis involving a mesh prosthesis placed é years before in the right para-rectal area. The pathology report of biopsies of the mesh confirmed a metastasis compatible with a pancreatic tumor. Discussion: Possible modes of metastasis and limited published data to date on mesh prosthesis metastasis are presented. This situation can be assimilated to port-site metastasis after laparoscopy. Conclusion: A mesh prosthesis metastasis after laparoscopic hernia repair is very rare., SCOPUS: ar.j, info:eu-repo/semantics/published

The aim of this case report is to outline the challenge and the feasibility of laparoscopic gastric bypass in a patient with situs inversus totalis. Situs inversus totalis does not seem to be a contraindication for laparoscopic surgery., SCOPUS: ar.j, info:eu-repo/semantics/published

SCOPUS: sh.j, info:eu-repo/semantics/published