Active surveillance for low-grade appendiceal mucinous neoplasm (LAMN).

Objectives: Due to the scarcity of low-grade appendiceal mucinous neoplasm (LAMN), there is an absence of systematized guidelines concerning its management, especially after incidental finding on an appendiceal specimen. In this study, we evaluate the active surveillance (AS) strategy adopted for a series of patients diagnosed with LAMN on resection specimens who were considered to have a low risk of pseudomyxoma progression. Methods: Thirty patients were included between April 2014 and July 2021, with a female majority and a median follow-up period of 3.1 years. The inclusion criteria were as follows: LAMN diagnosis on appendiceal specimens, confirmed in an expert center, limited extra-appendiceal mucin resected and localized around the appendix, normal biology (CEA, CA199, CA125) and normal abdominopelvic MRI. AS included physical exam (trocar scar), biology and MRI, 6 months postoperatively, then yearly for 10 years. Results: As an initial surgery, 77 % had an appendectomy as their initial intervention, 17 % had a cecectomy, and 6 % had a right colectomy. After follow-up, 87 % of patients showed no sign of disease progression by MRI, while 13 % progressed to PMP. MRI performed in the first postoperative year predicted the disease prognosis in 97 % of patients. Conclusions: The AS strategy, based on MRI, is a valid option after incidental LAMN diagnosis.

Reasons for stopping Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC): A retrospective study to improve future patient selection.

To improve the prognosis and maintain quality of life in patients with peritoneal metastasis (PM), a novel treatment has been introduced-pressurized intraperitoneal aerosol chemotherapy (PIPAC). The majority of teams propose at least 3 PIPAC procedures. However, for many patients PIPAC is stopped after only one or two procedures. The aim of this study was to identify the reasons for stopping PIPAC after only one or two procedures and to establish a profile of poor candidates. This retrospective, multicenter cohort study included all patients who underwent PIPAC in three French expert centers between 2015 and 2021. A total of 268 PIPAC procedures were performed in 89 patients. Of them, 48.3% of patients underwent fewer than three procedures: 28.1% had one, 20.2% two and 51.7% three or more PIPAC procedures. The main reason for stopping PIPAC, regardless of the number of procedures, was disease progression, in 55.8% of cases. Other reasons for stopping PIPAC were non-access to the abdominal cavity (7.9%), conversion to cytoreductive surgery (13.5%), post-PIPAC adverse events (7.9%), patients' wishes (10.1%) and death (2.2%). In univariate analysis, patients who received fewer than three PIPACs less frequently had chemotherapy beforehand (91% vs 100%, p = 0.05), less frequently had bimodal treatment (70% vs 87%, p = 0.04), had more ascites (median 80 ml vs 50 ml, p = 0.05) and more frequently had carcinomatosic ascites (48.8% vs 23.9%, p < 0.01). Performing PIPAC alone in chemotherapy-naïve patients with ascites should be avoided.

Intraoperative appearance of radiation enteritis: What should be resected?

Radiation enteritis can appear up to 30 years after radiotherapy. Outside acute complications, it usually manifests itself as chronic intestinal obstruction. If medical treatment (corticosteroid therapy) fails, surgical treatment is indicated, namely resection of the affected bowel, with removal of the ileo-caecal valve.

A prediction model to refine the timing of an early second-look laparoscopic exploration in patients with colon cancer at high risk of early peritoneal metastasis recurrence.

BACKGROUND: In patients at high risk of peritoneal metastasis (PM) recurrence following surgical treatment of colon cancer (CC), second-look laparoscopic exploration (SLLE) is mandatory; however, the best timing is unknown. We created a tool to refine the timing of early SLLE in patients at high risk of PM recurrence. METHODS: This international cohort study included patients who underwent CC surgery between 2009 and 2020. All patients had PM recurrence. Factors associated with PM-free survival (PMFS) were assessed using Cox regression. The primary endpoint was early PM recurrence defined as a PMFS of <6 months. A model (logistic regression) was fitted and corrected using bootstrap. RESULTS: In total, 235 patients were included. The median PMFS was 13 (IQR, 8-22) months, and 15.7% of the patients experienced an early PM recurrence. Synchronous limited PM and/or ovarian metastasis (hazard ratio [HR]: 2.50; 95% confidence interval [CI]: [1.66-3.78]; p < 0.001) were associated with a very high-risk status requiring SLLE. T4 (HR: 1.47; 95% CI: [1.03-2.11]; p = 0.036), transverse tumor localization (HR: 0.35; 95% CI: [0.17-0.69]; p = 0.002), emergency surgery (HR: 2.06; 95% CI: [1.36-3.13]; p < 0.001), mucinous subtype (HR: 0.50; 95% CI [0.30, 0.82]; p = 0.006), microsatellite instability (HR: 2.29; 95% CI [1.06, 4.93]; p = 0.036), KRAS mutation (HR: 1.78; 95% CI: [1.24-2.55]; p = 0.002), and complete protocol of adjuvant chemotherapy (HR: 0.93; 95% CI: [0.89-0.96]; p < 0.001) were also prognostic factors for PMFS. Thus, a model was fitted (area under the curve: 0.87; 95% CI: [0.82-0.92]) for prediction, and a cutoff of 150 points was identified to classify patients at high risk of early PM recurrence. CONCLUSION: Using a nomogram, eight prognostic factors were identified to select patients at high risk for early PM recurrence objectively. Patients reaching 150 points could benefit from an early SLLE.

Distal Pancreatectomy with Celiac Axis Resection-with Posterior Ramps Approach-for Locally Advanced Pancreatic Adenocarcinoma with Celiac Trunk Infiltration (Modified Appleby Procedure) (with Video).

With the advent of FOLFIRINOX and neoadjuvant radiotherapy, the surgical indications for adenocarcinoma have expanded. Locally advanced pancreatic adenocarcinomas of the body/tail with infiltration of the celiac trunk which have a good clinical, biological, and radiological response to neoadjuvant treatment may therefore be eligible for caudal pancreatectomy with resection of the celiac trunk (modified Appleby procedure). In addition to rigorous patient selection and surgical expertise, this procedure also requires experience in interventional radiology.

Surgical management of pancreatic neuroendocrine tumors: an introduction.

Introduction: Neuroendocrine tumors of the pancreas (pNETs) represent only 1% to 2% of all pancreatic neoplasms. These tumors can be classified as functional or nonfunctional tumors; as sporadic or from a genetic origin; as neuroendocrine neoplasms or carcinoma. Over the last decade, diagnosis of pNETs has increased significantly mainly due to the widespread use of cross-sectional imaging. Those tumors are usually associated with a good prognosis. Surgery, the only curative option for those patients, should always be discussed, ideally in a multidisciplinary team setting.Areas covered: We discuss i), the preoperative management of pNETs and the importance of accurate diagnosis, localization, grading and staging with computed tomography, magnetic resonance imaging, endoscopic ultrasound, and nuclear medicine imaging; ii), surgical indications and iii), the surgical approach (standard pancreatectomy vs pancreatic-sparing surgery).Expert opinion: The treatment option of all patients presenting with pNETs should be discussed in a multidisciplinary team setting with surgeon's experienced in both pancreatic surgery and neuroendocrine tumor management. A complete preoperative imaging assessment - morphological and functional - must be performed. Surgery is usually recommended for functional pNETs, nonfunctional pNETs >2 cm (nf-pNETs) or for symptomatic nf-pNETs.