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Simple Summary The benefit of major cancer surgery among older patients may be limited, and it remains unclear how to optimally select suitable patients. By combining very simple geriatric (gait speed, and weight loss) and cancer parameters (cancer site and cancer extension), the pre-operative GRADE score > 8 was significantly associated with severe post-operative complications, and overall post-operative mortality among older patients with digestive or non-breast gynaecological cancer undergoing surgery. At the time of the first consultation, the GRADE score could help surgeons to choose the most suitable treatment strategy, avoiding under- or over-treatment, especially when a geriatric assessment is not available. Abstract We aimed to assess the prognostic value of the pre-operative GRADE score for long-term survival among older adults undergoing major surgery for digestive or non-breast gynaecological cancers. Between 2013 and 2019, 136 consecutive older adults with cancer were prospectively recruited from the PF-EC cohort study before major cancer surgery and underwent a geriatric assessment. The GRADE score includes weight loss, gait speed at the threshold of 0.8 m/s, cancer site and cancer extension. The primary outcome was post-operative 5-year mortality. Patients were classified as low risk (GRADE ≤ 8) or high risk (GRADE > 8) on the basis of the median score. A Cox multivariate proportional hazards regression model was performed to assess the association between pre-operative factors and 5-year mortality expressed by adjusted hazard ratio (aHR) and 95% CI. The median age was 80 years, 52% were men, 73% had colorectal cancer. The 30-day post-operative severe complication rate (Clavien-Dindo ≥ 3) was 37%. The 5-year post-operative mortality rate was 34.5%. A GRADE score ≥ 8 (aHR = 2.64 [1.34–5.21], p = 0.0002) was associated with post-operative mortality after adjustment for Body Mass Index < 21 kg/m2 and Instrumental Activities of Daily Living

Background/Purpose In order to avoid consequences of total splenectomy (including severe postsplenectomy sepsis), partial splenectomy (PS) is increasingly reported. Without guidelines and indications concerning a rarely-indicated procedure, a review of literature should be an asset. Methods A systematic review of all PSs from 1960 to December 2017 was performed, with special focus on surgical indications, sites of resection, approaches and techniques of vascular dissection and parenchymal section/hemostasis of the spleen, perioperative morbidity/mortality, including complications compelling to perform total splenectomy. Results Among 2130 PSs, indications for resection were hematological disease in 1013 cases and nonhematological conditions in 1078, including various tumors in 142 and trauma in 184. Parenchymal transection was performed using several techniques through the years, most frequently after having induced partial ischemia by splenic hilum vascular dissection/ligation. 371 laparoscopic/robotic PSs were reported. Rescue total splenectomy was required in 75 patients. Conclusions Although good results are probably overestimated by such a retrospective review, PS should be considered as a procedure associated with a low morbidity/mortality. Nevertheless, severe complications are also reported, and the need of total splenectomy should not to be minimized. Laparoscopic/robotic procedures are increasingly performed, with good results and rare conversions. Type of study Systematic review. Level of evidence IV.

Perioperative outcomes of repeat laparoscopic colorectal resection (LCRR) have not been extensively reported. Patients who underwent LCRR from 2010 to 2018 in an expert center were retrieved from a prospectively collected database and compared to 2:1 matched sample. Matching was based on demographics, surgical indication [colorectal cancer (CRC) or benign condition], and type of resection (right-sided resection or left-sided resection or proctectomy). Twenty-three patients underwent repeat LCRR with a median time of 36 months between the primary and the repeat LCRR. They were 12 (52%) men with a mean age of 64.9 years (31–87) and a median BMI of 21.4 kg/m2 (17.7–34). Indication for repeat LCRR was CRC, dysplasia, anastomotic stricture, and inflammatory bowel disease in 11 (48%), 5 (22%), 4 (17%), and 3 (13%) patients, respectively. A right-sided resection, a left-sided resection, and proctectomy were reported in 11 (48%), 8 (35%), and 4 (17%) patients, respectively. Median blood loss reached 211 mL (range 0–2000 mL). Thirteen (57%) patients required conversion to laparotomy including 12 for intense adhesions. The median length of hospital stay was 7.5 days (5–20). Two (9%) major complications (Clavien–Dindo ≥ 3) were reported: 1 (4%) anastomotic fistula and 1 (4%) postoperative hemorrhage, without mortality. Among patients who underwent repeat LCRR for CRC, histopathological examination showed R0 resection in all patients, with at least 12 lymph nodes harvested in ten (91%) patients. After matched case–control analysis that compared to primary LCRR, conversion rate (p = 0.03), operative time (p = 0.03), and intraoperative blood loss (p = 0.0016) were significantly increased in repeat LCRR, without impact on postoperative outcomes. Repeat LCRR seems to be feasible and safe in expert hands without compromising the oncologic outcomes. Intense postoperative adhesions and misidentification of blood supply might lead to conversion to laparotomy. Real benefits of laparoscopic approach for repeat LCRR should be assessed in further studies.

Obesity and its metabolic complications are characterized by subclinical systemic and tissue inflammation. In rodent models of obesity, inflammation and metabolic impairments are linked with intestinal barrier damage. However, whether intestinal permeability is altered in human obesity remains to be investigated. In a cohort of 122 severely obese and non-obese patients, we analyzed intestinal barrier function combining in vivo and ex vivo investigations. We found tight junction impairments in the jejunal epithelium of obese patients, evidenced by a reduction of occludin and tricellulin. Serum levels of zonulin and LPS binding protein, two markers usually associated with intestinal barrier alterations, were also increased in obese patients. Intestinal permeability per se was assessed in vivo by quantification of urinary lactitol/mannitol (L/M) and measured directly ex vivo on jejunal samples in Ussing chambers. In the fasting condition, L/M ratio and jejunal permeability were not significantly different between obese and non-obese patients, but high jejunal permeability to small molecules (0.4 kDa) was associated with systemic inflammation within the obese cohort. Altogether, these results suggest that intestinal barrier function is subtly compromised in obese patients. We thus tested whether this barrier impairment could be exacerbated by dietary lipids. To this end, we challenged jejunal samples with lipid micelles and showed that a single exposure increased permeability to macromolecules (4 kDa). Jejunal permeability after the lipid load was two-fold higher in obese patients compared to non-obese controls and correlated with systemic and intestinal inflammation. Moreover, lipid-induced permeability was an explicative variable of type 2 diabetes. In conclusion, intestinal barrier defects are present in human severe obesity and exacerbated by a lipid challenge. This paves the way to the development of novel therapeutic approaches to modulate intestinal barrier function or personalize nutrition therapy to decrease lipid-induced jejunal leakage in metabolic diseases. Copyright © 2018 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Background. Surgical innovation from surgeon’s standpoint has never been scrutinized as it may lead to understand and improve surgical innovation, potentially to refine the IDEAL (Idea, Development, Exploration, Assessment, Long-term Follow-up) recommendations. Methods. A qualitative analysis was designed. A purposive expert sampling was then performed in organ transplant as it was chosen as the ideal model of surgical innovation. Interviews were designed, and main themes included the following: definition of surgical innovation, the decision-making process of surgical innovation, and ethical dilemmas. A semistructured design was designed to analyze the decision-making process, using the Forces Interaction Model. An in-depth design with open-ended questions was chosen to define surgical innovation and ethical dilemmas. Results. Interviews were performed in 2014. Participants were 7 professors of surgery: 3 in liver transplant, 2 in heart transplant, and 2 in face transplant. Saturation was reached. They demonstrated an intuitive understanding of surgical innovation. Using the Forces Interaction Model, decision leading to contemporary innovation results mainly from collegiality, when the surgeon was previously the main factor. The patient is seemingly lesser in the decision. A perfect innovative surgeon was described (with resiliency, legitimacy, and no technical restriction). Ethical conflicts were related to risk assessment and doubts regarding methodology when most participants (4/7) described ethical dilemma as being irrelevant. Conclusions. Innovation in surgery is teamwork. Therefore, it should be performed in specific specialized centers. Those centers should include Ethics and Laws department in order to integrate these concepts to innovative process. This study enables to improve the IDEAL recommendations and is a major asset in surgery.

With an increasing postoperative survival and prolonged follow-up, late complications following pancreaticoduodenectomy (PD) have yet to be thoroughly described and analyzed. Among those, pancreatic anastomosis stricture may lead to severe consequences. A systematic review focusing on pancreaticojejunostomy anastomosis (PJA) stricture. PJA stricture incidence reached 1.4–11.4% with a median time interval of 34 months after PD. No risk factor was identified. PJA stricture repercussions were inconsistent but postprandial abdominal pain and recurrent acute pancreatitis were the most common symptoms, followed by impaired pancreatic function. To confirm diagnosis, secretin-enhanced magnetic resonance cholangiopancreatography (SMRCP) sensitivity reached 56–100%. As impaired pancreatic function is not improved by any procedure, only PJA stricture leading to abdominal pain or acute pancreatitis should be considered for treatment. Endoscopic techniques (mainly ultrasound-assisted “rendezvous”) should be proposed prior to surgical repair, with a morbidity, an overall technical and clinical success reaching 16.5–33% and 28.6–100% and 33–100%, respectively. Regarding surgical repair, overall morbidity varied between 14.3 and 33%, with a clinical success reaching 26.1–100%. Finally, total pancreatectomy with islet auto-transplantation should be considered only for pain intractable to medical management and recurrent acute pancreatitis which has failed medical, endoscopic, and traditional surgical management strategies. PJA stricture following PD is a late, unusual, and potentially serious complication. When there is currently no clear consensus, PJA stricture leading to abdominal pain or acute pancreatitis should be considered treatment. With increasing survival after PD, further studies should focus on late complications. Stricture of pancraticojejunostomy is a late and potentially serious complication after pancreaticoduodenectomy. Incidence reaches 1.4–11.4% and no risk factor is identified. Symptoms are inconsistent but postprandial abdominal pain, recurrent acute pancreatitis, and impaired pancreatic function are the most frequent. To confirm diagnosis, secretin-enhanced magnetic resonance cholangiopancreatography is the best modality. Only PJA stricture leading to abdominal pain or acute pancreatitis should be considered for treatment. Endoscopic techniques (mainly ultrasound-assisted “rendezvous”) should be proposed prior to surgical repair. Finally, total pancreatectomy with islet auto-transplantation should be considered only for pain intractable to medical management and recurrent acute pancreatitis which has failed medical, endoscopic, and traditional surgical management strategies.

Among the criteria used to diagnose metabolic syndrome (MS), obesity and diabetes mellitus (DM) are associated with poor postoperative outcomes following colectomy. MS is also associated with colorectal cancer (CRC) and diverticulosis, both of which may be treated with colectomy. However, the effect of MS on postoperative outcomes following laparoscopic colectomy has yet to be clarified. In an academic tertiary hospital, data from all consecutive patients undergoing laparoscopic colectomy from 2005 to 2014 were prospectively recorded and analysed. Patients presenting with MS [defined by the presence of three or more of the following criteria: elevated blood pressure, body mass index > 28 kg/m2, dyslipidemia (decreased serum HDL cholesterol, increased serum triglycerides) and increased fasting glucose/DM] were compared with patients without MS regarding peri-operative outcome [mainly anastomotic leaks, severe postoperative complications (Clavien–Dindo III and IV)] and mortality. Overall, 1236 patients were included: 508 (41.1%) right colectomies and 728 (58.9%) left colectomies. Seven hundred seventy-two (62.4%) of these procedures were performed for CRC. MS was diagnosed in 85 (6.9%) patients, who were significantly older than the others (70 vs. 64.2 years, p

International audience; Background & aims: the obesity survival paradox is an emergent issue in oncology, but its existence remains unclear particularly in older cancer patients. We aimed to assess the obesity survival paradox in older cancer patients.Methods: all consecutive cancer outpatients 65 years and older referred for geriatric assessment (GA) before a decision on cancer treatment between November 2013 and September 2016 were enrolled in the PF-EC cohort study. The main outcome was 6-month mortality. A Cox univariate and multivariate proportional hazard regression models were performed with baseline GA, oncological variables (cancer site, extension and treatment modalities) and C-reactive protein (CRP). We assessed the prognostic value of body mass index categories (i.e. malnutrition = 30 kg/m(2)) in the whole study population and according to the metastatic status.Results: 433 patients with a mean age of 81.2 +/- 6.0 years were included, 51% were women, 44.3% had digestive cancers, 18% breast cancer and 14.5% lung cancer and 45% metastatic cancers. Eighty-eight of these patients (20.3%) were obese at baseline. Mortality rate was 17% during the 6-month follow-up period. After adjustment for sex, gait speed, Mini-Mental State Examination, cancer site and exclusive supportive care, obesity (compared to normal weight) was independently and negatively associated with 6-month mortality only in metastatic patients (aHR 0.17, 95% CI [0.03-0.92], P = 0.04).Conclusion: our study confirms the obesity survival paradox in older cancer patients only in the metastatic group. (C) 2018 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism.

Intraoperative enteroscopy (IOE) to explore obscure gastrointestinal bleeding is now rarely indicated. IOE allows complete small bowel exploration in 57% to 100% of cases, finds a bleeding source in 80% of cases, allows the recurrence-free management of gastrointestinal bleeding in 76% of cases, but carries a high morbidity and mortality. IOE only remains indicated to guide the intraoperative treatment of preoperatively identified small bowel lesions when nonoperative treatments are unavailable and/or when intraoperative localization by external examination is impossible.

As the most appropriate laparoscopic approach for adrenalectomy is still a matter of debate, we present a modified technique of laparoscopic transmesocolic approach for left adrenalectomy. All demographics, intraoperative and postoperative data of patients who underwent laparoscopic transmesocolic left adrenalectomy from 2009 to 2015 in Avicenne Hospital were recorded. Thirty-three consecutive patients underwent laparoscopic transmesocolic left adrenalectomy. We observed no conversion, negligible blood loss, no red cell transfusion or intraoperative complication. Mean operative time reached 96 min (range: 40–200 min). Postoperatively, the median length of hospital stay was 5 days (range: 3–8 days), mortality was nil, and six (19%) patients suffered from complication, including one major complication (Clavien–Dindo III–IV, an abdominal collection treated with radiologic drainage). R0 resection was achieved in all patients. Laparoscopic left adrenalectomy using semi-lateral transperitoneal transmesocolic approach is feasible and safe with acceptable intraoperative and perioperative outcomes. This technique could be considered as a routine approach and should be compared in further studies.

Purposes: Accurately localizing colorectal cancer during surgery may be challenging due to intraoperative limitations. In the present study, localization of left-sided colon cancer (LCC) by...

Hepatectomy remains the only curative option in patients presenting with colorectal liver metastases (CLM). Although laparoscopic approach has improved postoperative morbidity and mortality rates, its suitability for patients of all age groups has yet to be confirmed. The aim of this study was to analyze postoperative outcomes following laparoscopic liver resection (LLR) in different age groups of patients presenting with CLM.All patients who underwent LLR for CLM from 2008 to 2017 were reviewed. Patients were divided into four age groups: 55, 55-65 years, 65-75 and 75 years. Baseline and intraoperative characteristics as well as postoperative morbidity and mortality were compared between all four groups.Overall, 335 patients were included with 34 (10%), 113 (34%), 136 (41%) and 52 (15%) in 55, 55-65, 65-75 and 75 years subgroups. Baseline characteristics were similar between all four groups except for elevated pressure, dyslipidemia and ASA score which were higher in older patients. Regarding surgical procedures, major hepatectomy, uni- or bisegmentectomy and wedge resection were performed in 122 (36%), 87 (26%) and 126 (38%) patients, respectively, with no significant differences between age groups. Overall, 90-day postoperative mortality rate was nil and postoperative morbidity was similar between all four groups except for biliary fistula occurrence, which was higher in 55 years patients (p = 0.006).Short-term postoperative outcome following LLR for CLM does not seem to be affected by age. Curative laparoscopic treatment should therefore be considered whenever possible, regardless of patient age.

Gallstone ileus is an uncommon clinical presentation of complicated biliary lithiasis that mostly occurs in the elderly without specific signs. Various types of surgical management have been proposed: primary enterolithotomy, enterolithotomy, cholecystectomy and fistula closure (one stage), or enterolithotomy with delayed cholecystectomy (two stage). All are associated with a high complication rate. We present a video of a laparoscopic cololithotomy for gallstone ileus caused by a gallstone impacted in the sigmoid colon. As a safe and feasible procedure, enterolithotomy appears to be the treatment of choice based on the scientific literature, especially in frail patients. However, except in case of an impacted gallstone in a colorectal cancer, colon resection is not mandatory. Further surgery (such as cholecystectomy or colectomy in benign disease such as diverticulosis) may be selectively considered.

Although association between colorectal cancer (CRC) and metabolic syndrome (MetS) is established, specific features of CRC arising in patients presenting with MetS have not been clearly identified. All patients who underwent colectomy for CRC from January 2005 to December 2014 at Institut Mutualiste Montsouris were identified from a prospectively collected database and characteristics were compared in the entire population and in a 1:2 matched case-control analysis [variables on which matching was performed were CRC localization (right- or left-sided) and AJCC stage (0 to IV)]. Out of the 772 identified patients, 98 (12.7%) presented with MetS. Entire population analysis revealed that CRC associated with MetS was more frequent in men (71.4 vs. 47.8%, p

Introduction La prise en charge de patients en oncologie digestive est parfois complexe, du fait d’antecedents therapeutiques lourds (chirurgie, radiofrequence, radiotherapie). L’objectif est d’evaluer l’apport du TEP/MR dans le bilan des recidives des tumeurs abdominopelviennes. Methodes Vingt-neuf patients du service d’oncologie digestive de l’hopital Avicenne etaient inclus prospectivement, entre fevrier 2016 et mai 2017, dans un contexte d’elevation des marqueurs ou d’apparition de nouvelles lesions durant le suivi. Tous les patients ont eu un TEP/MR qui a suivi un bilan conventionnel associant un scanner (n = 18/29), une IRM (n = 14/29) et un TEP/TDM au FDG (n = 29/29). Le TEP/IRM etait realise a la suite du TEP/TDM comprenant les sequences suivantes : Dixon (correction d’attenuation), axiales T2, DWI et T1 W post-contraste. Les dossiers des patients ont ete discutes en RCP de chirurgie digestive. Les constatations en imagerie et les decisions therapeutiques durant la RCP disposant des informations du bilan conventionnel ont ete relevees. Dans un second temps, apres introduction dans la discussion des resultats du TEP/IRM, les changements dans les decisions therapeutiques ont ete notes. Resultats Le TEP/MR a apporte des informations supplementaires chez 11/29 (38 %) patients : negativation de lesions suspectes hepatiques (3/11), ganglionnaires ou peritoneales (2/11) ou extra-abdominales (3/11) ; lesions additionnelles ganglionnaires et/ou peritoneales (2/11) et extra-abdominale (1/11). L’introduction des resultats de TEP/MR pendant la RCP a conduit a un changement de decision therapeutique chez 4 patients (14 %) : chirurgie a la place d’une chimiotherapie (n = 1), changement considere comme pertinent car confirme par la chirurgie (lesion hepatique suspecte decrite comme steatose en TEP/IRM) ; chirurgie a la place de la chimiotherapie, changement non pertinent du fait des constatations operatoires infirmant le TEP/IRM (carcinose non vue en imagerie) ; chirurgie a la place de la radiotherapie vertebrale, changement considere comme pertinent (lesion vertebrale suspecte, decrite comme benigne en TEP/IRM) ; chimiotherapie a la place de la chirurgie chez un patient avec carcinose peritoneale decrite comme repondant a la chimiotherapie en TEP/IRM. Conclusion Dans les dossiers complexes d’oncologie digestive, le TEP/MR peut apporter des informations supplementaires, pouvant conduire a des modifications des strategies therapeutiques chez un nombre significatif de patients.

Colorectal cancer (CRC) occurs mostly in the elderly. However, the biology of CRC in elderly has been poorly studied. This study examined the prevalence of deficient mismatch repair phenotype (dMMR) and BRAF mutations according to age.MMR phenotype was prospectively determined by molecular analysis in patients of all ages undergoing surgery for CRC. BRAF V600E mutation status was analysed in a subset of dMMR tumours.A total of 754 patients who underwent surgery between 2005 and 2008 were included in the study. Amongst them, 272 (36%) were ≥75years old. The proportion of women75 was 38% and that ≥75 was 53% (p0.0001). The prevalence of dMMR was 19.4% in patients ≥75 and 10.7% in patients75 (p=0.0017). For patients ≥75, the prevalence of dMMR was significantly higher in women than in men (27% vs 10.2%, respectively; p=0.003) but was similar in women and men75 (12.5% vs 9.7%, respectively; p=0.4). We examined BRAF mutation status in 80 patients with dMMR tumours. The V600E BRAF mutation was significantly more frequent in patients ≥75 than in patients75 (72.2% vs 11.4%, respectively; p0.001). In patients ≥75, there was no difference in the prevalence of the BRAF V600E mutation according to sex (78% in women and 70% in men, p=0.9).The prevalence of dMMR in CRC is high in patients over 75. In elderly patients, dMMR tumours are significantly more frequent in women than in men. The BRAF mutation is frequent in elderly patients with CRC.

But Analyser la survie apres resection de recidive ganglionnaire d’un cancer colorectal. Methodes Etude monocentrique retrospective (2007–2017) observationnelle incluant tous les patients ayant ete reseques d’une recidive ganglionnaire d’un cancer colorectal. Resultats Un total de 7 patients dont 4 femmes d’un âge median de 60 ans (38 a 69 ans) etaient inclus. Les tumeurs etaient classees T3 (71 %) ou T4 (28 %), dont 86 % de N+ et 43 % de metastases synchrones. Toutes les recidives ganglionnaires etaient lombo-aortiques (86 %) ou pelviennes, suspectees sur des scanners et Pet-scans consecutifs, affirmees sur les pieces operatoires. Le delai median entre la resection du primitif et celle de la recidive ganglionnaire etait de 29 mois (8 a 57 mois). Une seule complication etait associee a la resection ganglionnaire (fistule colo-vesicale). Tous les patients ont beneficie d’un traitement adjuvant associant chimiotherapie et radiotherapie ; 3 (43 %) patients ont finalement recidive, 1 (14 %) patient est decede apres 25 mois, pour une survie mediane sans recidive 36 mois (0 a 117 mois) et une survie globale de 69 mois (25 a 117 mois). Conclusions La resection chirurgicale d’une recidive ganglionnaire d’un cancer colorectal peut s’integrer dans une prise en charge multimodale, offrant une survie prolongee.

Resume Introduction Malgre la frequence des eventrations complexes (EC), leurs modalites de reparation y compris la place des protheses sont mal codifiees, particulierement en situation contaminee. Notre objectif etait de connaitre les pratiques des chirurgiens universitaires francais prenant en charge ces EC pour ce qui est des indications, des techniques les plus adaptees, du type de prothese eventuelle utilisee, et des complications observees. Methode Une enquete nationale comprenant 21 questions et 6 scenarios a ete envoyee par e-mail aux chirurgiens universitaires francais prenant en charge des EC. Resultats Parmi 54 chirurgiens sollicites, 40 (74,0 %) ont repondu a l’enquete, representant 29 centres hospitalo-universitaires francais. Parmi les techniques de reparation des EC, on retrouvait la fermeture primaire sans prothese (31,6 %), le lambeau d’avancement musculaire sans prothese (43,7 %), une prothese positionnee en pont (16,5 %) et la reduction de la taille du defect par aponevrotomies de decharge sans prothese (8,2 %). Parmi les 40 repondeurs, 36 chirurgiens avaient deja utilise une prothese biologique (PB). Il existait un consensus fort parmi les repondeurs pour ne pas utiliser de prothese synthetique en milieu contamine ou infecte (100 %), mais de l’utiliser en chirurgie propre (100 %). Un consensus existait egalement pour ce qui est de l’utilisation des PB en milieu contamine (82,5 %) ou infecte (77,5 %) et pour ne pas les utiliser en chirurgie propre (95 %). En chirurgie propre-contaminee, il n’existait pas de consensus sur la strategie therapeutique optimale. L’infection etait la complication la plus frequemment reportee apres utilisation de PB (58 %). Les facteurs qui influencaient les chirurgiens dans leur pratique d’utilisation des PB dans le traitement des EC etaient la litterature medicale, les congres et la discussion avec les collegues (85,0 %), leur propre experience (45,0 %) et le cout (40,0 %). Conclusions Malgre l’absence de niveau de preuve eleve, les PB ont deja ete utilisees par 90 % des chirurgiens universitaires interroges dans l’EC. Il existait un fort consensus pour les utiliser en situation infectee ou contaminee et pour ne pas les utiliser en chirurgie propre. Des etudes randomisees sont necessaires pour evaluer les benefices a court et long-terme des PB en fonction du degre de contamination parietale.

This case highlights the need for the combination of information provided by fluorodeoxyglucose PET/CT and liver MR imaging in the diagnosis of a rare liver tumor.

Les cancers du colon atteignent principalement les patients âges. La prise en charge chirurgicale a fait des progres mais l’indication d’une chimiotherapie adjuvante reste controversee. Le choix du schema therapeutique et la selection des patients a traiter est un enjeu majeur. Des essais prospectifs specifiques a la population âgee sont necessaires.

Obscure gastrointestinal bleeding has long been a diagnostic challenge because of the relative inaccessibility of small bowel to standard endoscopic evaluation. Intraoperative enteroscopy indications have been reduced by the development of deep enteroscopy techniques and video capsule endoscopy. In light of the current advances, this review aimed at evaluating the intraoperative enteroscopy technical aspects, study results and an ongoing role for intraoperative enteroscopy in obscure gastrointestinal bleeding management. Intraoperative enteroscopy allows complete small bowel exploration in 57-100% of cases. A bleeding source can be identified in 80% of cases. Main causes are vascular lesions (61%) and benign ulcers (19%). When a lesion is found, intraoperative enteroscopy allows successful and recurrence-free management of gastrointestinal bleeding in 76% of cases. The reported mortality is 5% and morbidity is 17%. The recurrence of bleeding is observed in 13-52% of cases. With the recent development of deep enteroscopy techniques, intraoperative enteroscopy remains indicated when small bowel lesions (i) have been identified by a preoperative work-up, (ii) cannot be definitively managed by angiographic embolization, endoscopic treatment or when surgery is required and (iii) cannot be localized by external examination during surgical explorations. Surgeons and endoscopists must exercise caution with intraoperative enteroscopy to avoid the use of a low yield, highly morbid procedure.

Intraoperative enteroscopy (IOE) to explore obscure gastrointestinal bleeding is now rarely indicated. IOE allows complete small bowel exploration in 57% to 100% of cases, finds a bleeding source in 80% of cases, allows the recurrence-free management of gastrointestinal bleeding in 76% of cases, but carries a high morbidity and mortality. IOE only remains indicated to guide the intraoperative treatment of preoperatively identified small bowel lesions when nonoperative treatments are unavailable and/or when intraoperative localization by external examination is impossible.

IF 2.719; International audience; Colorectal cancers are common in elderly patients. However, cancer screening is poorly used after 75. Elderly patients form a heterogeneous population with specific characteristics. Standards of care cannot therefore be transposed from young to elderly patients. Tumour resection is frequently performed but adjuvant chemotherapy is rarely prescribed as there are no clearly established standards of care. In a metastatic setting, recent phase III studies have demonstrated that doublet front-line chemotherapy provided no survival benefit. Moreover, several studies have established the benefit of bevacizumab in association with chemotherapy. There is a lack of evidence for the efficacy of anti-epidermal growth factor antibodies in elderly patients. Geriatric assessments could help to select the adequate treatment strategy for individual patients. Geriatric oncology is now the challenge we have to face, and more specific trials are needed. (C) 2016 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Les cancers digestifs sont frequents chez les patients âges. Cependant, en dehors des cancers colorectaux, les etudes specifiques aux patients âges evaluant la prise en charge de ces cancers sont rares. Il apparait que chez des patients correctement selectionnes des traitements valides chez les patients plus jeunes sont applicables. L’adaptation du traitement a chaque cas doit faire l’objet d’une discussion pluridisciplinaire impliquant un geriatre.

Complicated Meckel's diverticulum represents a common etiology of acute abdomen in children. However, this condition is less frequent in adults. We reviewed the records of adult patients who underwent the surgical removal of complicated Meckel's diverticulum between 2001 and 2017 at 2 tertiary French medical centers. We then analyzed the clinical characteristics, mode of presentation, and management for all patients.The Meckel's diverticulum was resected in 37 patients (24 males and 13 females). The mean patient age was 46.1 ± 21.4 years. The most common clinical presentations of complicated Meckel's diverticulum were diverticulitis (35.1%, n = 13), small-bowel obstruction (35.1%, n = 13), and gastrointestinal bleeding (29.8%, n = 11) (anemia, n = 1; hematochezia, n = 10). Age distribution was significantly different (P = .02) according to the 3 Meckel's diverticulum complications: patients with diverticulitis (P = .02) were statistically more frequently over 40 (P = .05), significantly older than patients with gastrointestinal bleeding who were more frequently

Objective: Continuous intravenous infusion of somatostatin improves the natural course of digestive fistulae. Lanreotide 30 mg PR is a synthetic analogue of somatostatin with pharmacological activity extending to at least 10 days after intramuscular administration. Its effectiveness was assessed in patients with simple externalized digestive fistulae in a randomized, double-blind, placebo-controlled study. Methods: Patients demonstrating a reduction of at least 50% of fistula output within 72 hours after a first double-blind intramuscular injection of lanreotide or placebo were considered to be responders (primary end point) and continued the double-blind treatment to a maximum of 6 injections at 10-day intervals. Other endpoints included fistula closure rate and time to closure. Blind was lifted for nonresponders, and those initially on placebo were then treated with open-label lanreotide. Results: Following the first double-blind injection, 35 of 54 patients (64.8%) on lanreotide were responders versus 20 of 53 (37.7%) on placebo, ie, a 3.1 times higher response likelihood on lanreotide compared with placebo (P = 0.006). Group mean reduction of fistula output at 72 hours was 45.1% and 8.9%, respectively (P = 0.005). Lanreotide compared with placebo had no effect on closure rate which averaged 77% but median time to fistula closure was shorter on lanreotide, based on Kaplan-Meier analysis, although no statistical significance was achieved. Conclusion: Compared with placebo, intramuscular lanreotide 30 mg PR significantly decreases digestive fistulae output at Day 3 and shortens time to fistula closure by 9 days. ClinicalTrials.gov registration number: NCT00729313.

Resume Objectif Nous rapportons un cas de cancer medullaire de la thyroide decouvert par TEP au 18 FDG. Patient et methodes Un homme de 73 ans opere d’un cancer du colon, avec ablation du sigmoide, a beneficie d’une tomographie par emission de positron au 18 fluorodeoxyglucose (TEP au 18 FDG), devant un taux eleve d’ACE et un nouvel episode d’occlusion, a la recherche de metastases a distance ou de recidive locoregionale. Les images obtenues ont montre une hyperfixation du FDG dans le lobe thyroidien droit. L’echographie thyroidienne a montre un nodule dans chaque lobe. Resultats Le resultat de la cytoponction etait suspect et le taux de calcitonine etait eleve. Le patient a ete opere d’une thyroidectomie sans curage. L’examen anatomopathologique a revele un cancer medullaire de la thyroide de 14 mm. Aucune mutation germinale du gene RET n’a ete retrouvee. Conclusions La TEP au 18 FDG peut detecter des cancers thyroidiens primitifs ou secondaires. Aussi, un incidentalome thyroidien decouvert sur une TEP au 18 FDG necessite une evaluation attentive.

Background This study aimed at evaluating the role of intraoperative enteroscopy (IOE) for the management of obscure gastrointestinal (GI) bleeding in patients who had been preoperatively explored by video-capsule endoscopy (VCE). Methods Eighteen patients who underwent IOE for obscure GI bleeding were prospectively recorded between November 2000 and January 2007. The bleeding site was preoperatively localized by VCE in the small bowel in 15 patients, but the origin of bleeding remained unknown in 3 patients. Results In the 3 patients with negative VCE, IOE was normal, but intraoperative conventional endoscopy identified gastric (n = 1) and colonic (n = 2) lesions. Among the 15 patients with VCE positive for small-bowel lesions, laparotomy and IOE yielded localization and treatment (surgical n = 11 and endoscopic n = 2) guidance for 13 of 15 (87%) lesions. At median 19-month follow-up, 3 bleeding recurrences (3 of 15 [20%]) were recorded, resulting in a 73% therapeutic efficacy of IOE. Conclusions IOE remains useful for the management of obscure GI bleeding when preoperative VCE is positive for small-bowel lesions that are not reachable by nonoperative enteroscopy. When VCE is negative, new conventional endoscopy should be proposed instead of IOE.

Purpose Many patients who present with early-stage colorectal cancer (International Union Against Cancer TNM stages I and II) are nevertheless at high risk of relapse. We hypothesized that intratumoral immune reaction could influence their prognosis. Patients and Methods The intratumoral immune reaction was investigated in 29 tumors by large-scale real-time polymerase chain reaction. Cytotoxic (CD8) and memory (CD45RO) T cells were quantified by immunohistochemical analyses of tissue microarrays from the center (CT) and the invasive margin (IM) of the 602 tumors from two independent cohorts. The results were correlated with tumor recurrence and patient survival. Results Patients with a strong infiltration of CD45RO+ cells in the tumor exhibited an increased expression of T-helper 1 and cytotoxicity-related genes. Densities of CD45RO+ and CD8+ cells in tumor regions (CT/IM) classified the patients into four distinct prognostic groups based on the presence of high density of each marker in each tumor region. The four groups were associated with dramatic differences in disease-free, disease-specific, and overall survival (all P < .0001). Five years after diagnosis, only 4.8% (95% CI, 0.6% to 8.8%) of patients with high densities of CD8+ plus CD45RO+ cells had tumor recurrence, and 86.2% (CI, 79.4% to 93.6%) survived. In contrast, the tumor recurred in 75% (95% CI, 17% to 92.5%) of patients with low densities of these cells, and only 27.5% (95% CI, 10.5% to 72%) survived (all P < .0001). Multivariate analyses showed that the immune criteria had independent effects on the rates of complete remission and survival. Conclusion The combined analysis of CD8+ plus CD45RO+ cells in specific tumor regions could provide a useful criterion for the prediction of tumor recurrence and survival in patients with early-stage colorectal cancer.

Aims: The Epidermal Growth Factor-Receptor (EGF-R) is frequently overexpressed in colorectal carcinoma (CRC) and patients can benefit from anti-EGF-R therapy. Yet, the relationship, within tumours, between EGF-R and the activity of downstream effectors such as the non-receptor tyrosine kinase p60c-src and the signal transducer and activator of transcription 3 (STAT3) has not been extensively analyzed. Methods and results: We evaluated EGF-R, tyrosine 416-phosphorylated p60c-src (P-p60c-src), STAT3 and tyrosine 705- phosphorylated STAT3 (P-STAT3) on Tissue Micro Array (TMA) from 126 patients with CRC. Composite immunohistochemistry scores based on the intensity of labelling and the percentage of positive cells were determined on TMA for EGF-R, P-p60c-src, STAT3 and P- STAT3. A high score was found in 56%, 61%, 62% and 27% of the cases for EGF-R, P-p60c-src, STAT3 and P-STAT3 respectively. There was a significant correlation between EGF-R and P-p60c-src (p =0 .006) and between P-p60c-src and P-STAT3 (p =0 .0009). STAT3 was significantly correlated with vascular emboli ( p =0 .03) and perineural invasion (p =0 .02). Conclusions: The correlations between EGF-R, P-p60-src and P-STAT3 and some stage-related pathological features point to a critical role for a EGF-R-connected p60c-src-kinase-mediated pathway involving STAT3 and contributing to cell survival and proliferation within CRC tumours.

The role of the adaptive immune response in controlling the growth and recurrence of human tumors has been controversial. We characterized the tumor-infiltrating immune cells in large cohorts of human colorectal cancers by gene expression profiling and in situ immunohistochemical staining. Collectively, the immunological data (the type, density, and location of immune cells within the tumor samples) were found to be a better predictor of patient survival than the histopathological methods currently used to stage colorectal cancer. The results were validated in two additional patient populations. These data support the hypothesis that the adaptive immune response influences the behavior of human tumors. In situ analysis of tumor-infiltrating immune cells may therefore be a valuable prognostic tool in the treatment of colorectal cancer and possibly other malignancies.

1Departement d'Oncologie Medicale, Hopital Pitie-Salpetriere, Paris; 2Departement d'Anatomopathologie, Hopital Avicenne, Bobigny; 3 Departement de Radiotherapie et Statistique, Hopital Europeen Georges Pompidou, Paris; 4 Departement d'Oncopharmacologie, Centre Antoine Lacassagne, Nice; 5 Departement de Gastro-Enterologie, Hopital Avicenne, Bobigny; 6 Departement de Chirurgie Viscerale, Hopital Bobigny, Bobigny; 7 Departement d'Oncologie Medicale, 8 Departement d'Hematobiologie, 9 Departement de Biochimie et de Biologie Moleculaire, Hopital Avicenne, Bobigny; 10 Departement d'Anatomopathologie, Centre Anticancereux, Clermont-Ferrand, France Background: Epidermal growth factor receptor (EGFR) is overexpressed in many types of cancers, especially colorectal cancer (CRC), and seems to reflect more aggressive histological and clinical behaviors. The aim of this study was to evaluate EGFR immunohistochemical reactivity in CRC biopsies, and to analyze its relationship with various histological and clinical characteristics and survival. Patients and methods: A composite EGFR score, obtained by multiplying the grade (% positive cells) by the intensity of labeling (0-9) was used to define patients with low or high EGFR expression whose clinicopathological features were then compared. Univariate tests and multivariate Cox proportional hazards model were applied for data analysis. Results: Tissue sections from 150 CRC patients with a median follow-up of 40 months were examined. Median patient age at diagnosis was 70 years (range 38-89 years). EGFR reactivity was positive for 143 patients (97%) and high for 118 (80%). According to multivariate analysis, EGFR overexpression was significantly associated with tumor stage, with a higher percentage of EGFR overexpression in T3 than T4 (P=0.003) and not with overall survival. Conclusions: EGFR was overexpressed in this CRC patient population and was significantly associated with TNM (tumor-node-metastasis) stage T3. In the context of a new therapeutic strategy using EGFR-targeted therapies, although EGFR remains a controversial prognostic factor, this expression-stage association may play a crucial role in a decision to initiate an adjuvant treatment.

Resume Introduction. – La hernie diaphragmatique est une complication rare apres œsophagectomie pour cancer. Le but de ce travail a ete de rapporter une serie de sept patients et de preciser les caracteristiques de cette entite. Patients et methodes. – Sept patients (six hommes et une femme) âges de 61 a 68 ans ont ete operes d’une hernie diaphragmatique a distance d’une chirurgie pour cancer œsophagien (adenocarcinome n = 4, carcinome epidermoide n = 3). Tous ces patients avaient eu une œsophagectomie par voie abdominale trans-hiatale quatre fois et par voie trans-thoracique trois fois, avec dans tous les cas un agrandissement de l’orifice hiatal. Resultats. – Trois patients, tous symptomatiques, ont ete reoperes en urgence dans les deux annees suivant l’œsophagectomie. Parmi les quatre patients operes entre deux et sept ans apres l’œsophagectomie, deux etaient asymptomatiques. Le caractere symptomatique ou non de la hernie diaphragmatique n’etait lie ni a la technique de l’œsophagectomie, ni au type de phrenotomie (anterieure ou section du pilier). La hernie etait toujours symptomatique quand elle contenait du grele. Tous les patients ont ete operes par voie abdominale. La hernie contenait du colon trois fois, du grele une fois, et etait mixte trois fois. Une phrenotomie d’agrandissement etait necessaire six fois pour reduire la hernie. Deux patients ont eu une colectomie pour traiter une ischemie colique transverse peroperatoire. L’orifice diaphragmatique etait calibre autour de la plastie gastrique par suture simple six fois ou par prothese resorbable une fois. Il n’y a eu aucun deces. Avec un recul de un a cinq ans il n’y a pas eu de recidive de la hernie. Conclusion. – La hernie diaphragmatique apres œsophagectomie est due a une phrenotomie trop importante. Les formes precoces sont mal tolerees et necessitent une intervention urgente. La prevention des hernies diaphragmatiques apres chirurgie du cancer œsophagien repose sur un calibrage de l’orifice hiatal adapte a la largeur de la gastroplastie.

Objectifs En cancerologie digestive, l’interpretation de la TEP FDG se heurte a plusieurs problemes : mouvements des visceres, fixations physiologiques, detectabilite des petites lesions. Le TEP/IRM permet de resoudre en partie ces problemes : acquisition simultanee des images (meilleur recalage), image TEP mieux contrastee et mieux resolue, couplage avec une IRM multi-contraste, possibilite de synchronisation respiratoire. L’objectif etait de comparer le TEP/IRM aux methodes conventionnelles pour les bilans des cancers colorectaux (CCR). Methodes Quarante-quatre patients avec CRC ont passe un TEP/IRM au FDG (Signa, GE Healthcare) apres stadification conventionnelle incluant : TEP/FDG ( n = 44), scanner abdominal ( n = 27) et IRM ( n = 12). Les patients etaient explores pour un bilan initial ( n = 5), une suspicion de recidive ( n = 12) ou une evaluation post-therapeutique ( n = 25). Protocole TEP/IRM : 4 pas de 6 min synchronises a la respiration (SR), des sequences Dixon, axiales T2 SR, diffusion, foie multi-phases apres injection et T1 post injection (abdomen, pelvis) ; duree de l’examen 45 min. Les deux methodes ont ete evaluees en comparaison avec l’evaluation chirurgicale ou le suivi lorsqu’ils etaient disponibles. Resultats Les deux methodes, conventionnelle vs. TEP/IRM, ont montre des resultats pathologiques chez 75 % (33/44) et 86 % (38/44) des patients, respectivement. Une meilleure delimitation des lesions et/ou l’identification de lesions suspectes supplementaires par rapport aux procedures conventionnelles ont ete observees en TEP/IRM chez 41 % des patients (18/44). La stadification hepatique a ete amelioree en TEP/IRM chez 4 patients avec, cependant, un resultat faux positif (granulome). L’evaluation peritoneale a ete amelioree chez 6 patients avec une meilleure delimitation des petits implants ( Conclusions Le TEP/IRM, integrant une imagerie hepatique et des sequences de diffusion, est realisable en une session de 45 min., pour les evaluations pre ou post therapeutiques des CCR. Une modification des resultats, en comparaison avec les procedures conventionnelles, etait observee chez plus d’un tiers des patients, principalement en raison du taux de detection eleve de la TEP digitale et de l’integration pendant le processus d’interpretation des resultats de l’IRM multicontraste.

Nearly half of patients undergoing low anterior rectal cancer resection have a functional sequelae after straight coloanal or low colorectal anastomoses (SA), including low anterior rectal resection syndrome, which combines stool fragmentation, urge incontinence, and incontinence. SA are responsible for anastomotic leakage rates of 0 to 29.2 per cent. Adding a colonic reservoir improves the functional results while reducing anastomotic complications. These colonic reservoir techniques include the colonic J pouch (CJP), transverse coloplasty (TC), and side-to-end anastomosis (STEA) procedures. The aim of this literature review was to compare the functional outcomes of these three techniques from a high level of evidence. CJP with a 4- to 6-cm reservoir is a good surgical option because it reduces functional impairments during the first year, and probably up to 5 years, but is not always feasible. TC appears to perform as well as CJP, is achievable in over 95 per cent of patients, but still with some doubts about a higher anastomotic leakage rate and worse functional outcomes. STEA appears equivalent to CJP in terms of morbidity and even better functional outcomes. STEA, with a terminal side segment size of 3 cm, is feasible in the majority of nonobese patients, combines good functional results, has low anastomotic leakage rates, and is easy to complete.

First identified as a dedicated CREB (cAMP response element-binding protein) co-activator, CRTC1 (CREB-regulated transcription co-activator 1) has been widely implicated in various neuronal functions because of its predominant expression in the brain. However, recent evidences converge to indicate that CRTC1 is aberrantly activated in an expanding number of adult malignancies. In this study, we provide strong evidences of enhanced CRTC1 protein content and transcriptional activity in mouse models of sporadic (APC(min/+) mice) or colitis-associated colon cancer azoxymethane/dextran sulfate sodium (AOM/DSS-treated mice), and in human colorectal tumors specimens compared with adjacent normal mucosa. Among signals that could trigger CRTC1 activation during colonic carcinogenesis, we demonstrate that treatment with cyclooxygenase 2 (COX2) inhibitors reduced nuclear CRTC1 active form levels in colonic tumors of APC(min/+) or AOM/DSS mice. In accordance, prostaglandins E2 (PGE2) exposure to human colon cancer cell lines promoted CRTC1 dephosphorylation and parallel nuclear translocation, resulting in enhanced CRTC1 transcriptional activity, through EP1 and EP2 receptors signaling and consecutive calcineurin and protein kinase A activation. In vitro CRTC1 loss of function in colon cancer cell lines was associated with reduced viability and cell division rate as well as enhanced chemotherapy-induced apoptosis on PGE2 treatment. Conversely, CRTC1 stable overexpression significantly increased colonic xenografts tumor growth, therefore demonstrating the role of CRTC1 signaling in colon cancer progression. Identification of the transcriptional program triggered by enhanced CRTC1 expression during colonic carcinogenesis, revealed some notable pro-tumorigenic CRTC1 target genes including NR4A2, COX2, amphiregulin (AREG) and IL-6. Finally, we demonstrate that COX2, AREG and IL-6 promoter activities triggered by CRTC1 are dependent on functional AP1 and CREB transcriptional partners. Overall, our study establishes CRTC1 as new mediator of PGE2 signaling, unravels the importance of its dysregulation in colon cancer and strengthens its use as a bona fide cancer marker.

STUDY AIM: Esophageal squamous cell carcinomas are frequently associated with head and neck cancers. This retrospective study was conducted to compare the long-term outcome of the patients with a double cancer and of the patients with a solitary esophageal cancer after curative management. PATIENTS AND METHODS: From 1989 to 1999, 114 patients with an esophageal carcinoma were included in the study. Among them, 52 had an associated head and neck cancer (metachronous: n = 17 and synchronous: n = 35). Curative treatment was achieved in all patients. The patients were divided in "solitary" and "associated" group. RESULTS: Age, sex distribution, tumor location and histological findings were similar in the two groups. The esophageal resection was an esopharyngolaryngectomy (n = 13), a subtotal esophagectomy with cervical anastomosis (n = 92) and a Lewis-Santy esophagectomy with thoracic anastomosis (n = 9). Operative mortality (8 versus 7.7%), anastomotic leaks rate (14.5 versus 21%) and pneumonia rate (21 versus 9.6%) were not significantly different in the two groups. The mean hospital stay was 27 days. The mean follow-up was 85 +/- 50 months. Five-year survival rates were not significantly different in the two groups (p = 0.6411). In univariate survival analysis the only significant predictive factors were the depth of esophageal tumor invasion (p = 0.0002) and node involvement (p = 0.0373). The presence of head and neck cancer did not affect survival after esophagectomy. CONCLUSION: With an aggressive therapeutic plan, the survival of patients with an esophageal cancer associated to head and neck cancer was similar to the survival of patients with an isolated esophageal carcinoma. Long term esophageal survey seems to be useful to detect more superficial esophageal carcinomas in patients with head and neck cancer.

Background. The aim of this study was to report our experience with a new molecular tool to detect circulating enterocytes in the blood of patients with colorectal cancer. Methods. The study included 193 individuals: 78 patients with colorectal cancer and 115 controls composed of patients with benign colorectal diseases (n = 16), patients with noncolorectal cancer (n = 31), healthy individuals (n = 62), and healthy bone marrow transplantation donors (n = 6). A nested reverse transcriptase-polymerase chain reaction with specific primers for the carcinoembryonic gene member 2 (CGM2) was used to detect circulating enterocytes in the peripheral blood of 78 patients with colorectal cancer. The blood (n = 109) or the bone marrow (n = 6) of the 115 controls was studied to test the absence of CGM2 illegitimate transcription in nucleated blood cells and nucleated blood cell progenitors. The assay sensitivity was effective in detecting 1 CGM2-positive cell per 106 nucleated blood cells. Results. Fifty-nine percent (46/78) of patients with colorectal cancer were found positive whereas all negative controls remained negative. Positivity rates were 38% (3/8) in Dukes' A classification, 43% (9/21) in Dukes' B, 77% (23/30) in Dukes' C, and 58% (11/19) in Dukes' D. Conclusions. The clinical significance of enterocyte detection in the blood of colorectal cancer patients by means of this CGM2 messenger RNA assay needs further evaluation. (Surgery 2001;129:587-94.)

Treatment of intraductal papillary and mucinous tumors of pancreas (IPMT) usually requires surgery. The objective of this study was to evaluate the risk of recurrence in patients after surgery according to the histological nature of the neoplasm and the type of surgery.The outcome of 45 patients who underwent partial pancreatectomy (n = 35) or total pancreatectomy (n = 10) for IPMT was studied according to the nature of the neoplasm (invasive carcinoma or noninvasive neoplasm), type of surgery (partial or total pancreatectomy), and lymph nodes status.The overall 3-yr actuarial survival rate was 83%. Death occurred in seven of 20 (35%) patients with invasive carcinoma and in one of 26 (4%) patients with noninvasive tumors (p0.05). There were two recurrences in the seven patients with noninvasive neoplasm who underwent partial pancreatectomy with involved resection margins, and none in the 13 patients with disease-free margins. In patients with invasive carcinoma, there was one recurrence after total pancreatectomy, six after partial pancreatectomy with disease-free margins and six after partial pancreatectomy with involved margins. In patients with invasive carcinoma, total pancreatectomy and the absence of lymph nodes involvement were independently associated with a low risk of recurrence.IPMT may be managed as follows: 1) in patients with noninvasive neoplasms, partial pancreatic resection should be guided by frozen section examination until disease-free margins are obtained; and 2) in patients with invasive carcinoma, total pancreatectomy seems most likely to cure the patient, but should be discussed according to the general status and the age.

Esophageal squamous cell carcinomas are frequently associated with head and neck cancers. The poor prognosis of each cancer, and their proximity, often limit the treatment options. This study was conducted to determine the characteristics and long-term outcome of such dual cancers.We included 75 patients with esophageal carcinoma, of whom 25 had a synchronous head and neck malignancy. Curative treatment was possible in every case. The patients were divided into "solitary cancer" and "synchronous cancer" groups.The gender distribution, tumor location, and histological findings were similar in the two groups. Patients in the synchronous cancer group were younger than those in the solitary group (P0.0042). The operative mortality and pulmonary morbidity rates were not significantly different in the two groups. The rate of cervical anastomotic leaks was higher in the synchronous group (P0.05). The mean follow-up was 83 +/- 50 months. Five-year survival rates were not significantly different in the two groups (14.3% +/- 5.7% in the solitary group and 17.5% +/- 7.9% in the synchronous group).With aggressive treatment, the survival of patients with synchronous esophageal and head and neck cancers was similar to that of patients with isolated esophageal cancer.