[COSA 80: Oncologic surgery in the elderly patients]. / COSA 80 : chirurgie oncologique du sujet âgé de plus de 80 ans.

INTRODUCTION: Due to longer life expectancy, an increasing number of older people are at risk of developing cancer. Surgical resection of a non-metastatic and resectable digestive tumor remains the main therapeutic weapon. The objective of our study is to assess the possibility of curative oncological surgery in patients over 80years of age, to study its impact in terms of morbidity and mortality, and to look for risk factors for the occurrence of complications. PATIENTS AND METHODS: The study-included patients aged 80 and over operated on for digestive cancer in a curative situation. This was a multicenter prospective cohort study. A total of 230 patients were included in the study. In addition to demographic and medical data, the patients all benefited from an onco-geriatric assessment with the performance of various tests: WHO score, G8 score, IADL score, ADL score, mobility score, nutritional assessment, clock, thymic evaluation (Mini-GDS). Data collection of geriatric scores was repeated 3months postoperatively. RESULTS: Of a total of 230 patients, 51% were male and 49% female. The average age was 84.7years. Tumor localization was mainly colorectal (65.81%). Age had no influence on the mortality rate, with a mean age with no significant difference in the event of an unfavorable outcome or not (84.6 vs. 85years). The results at the different scores were then analyzed in search of a significant difference between preoperative and at 3months. The only significant difference found was in the number of patients with a WHO status of 0 (P=0.021). CONCLUSION: Our study shows that curative oncological surgery is possible in elderly patients without any adverse effect on their quality of life and level of postoperative autonomy. The multidisciplinary geriatric approach to the patient must make it possible to distinguish the patients who will benefit from a curative treatment and those in whom the benefit-risk balance is unfavorable.

Ectopic hormone-secreting pheochromocytoma: a francophone observational study.

BACKGROUND: Ectopic hormone-secreting pheochromocytomas are rare; only case reports exist in the literature. This condition has been linked with increased malignancy, familial syndromes, and ACTH secretion. We wanted to test these hypotheses and shed light on the nature of ectopic hormone-secreting pheochromocytomas. METHODS: This is a multicenter (francophone) observational study. Inclusion was based upon abnormal preoperative hormone tests in patients with pheochromocytoma that normalized after removal of the tumor. Where possible, immunohistochemistry was performed to confirm that ectopic secretion came from the tumor. RESULTS: Sixteen cases were found: nine female and seven male patients. Median age was 50.5 (range 31-89) years. Most presented with hypertension, diabetes, or cushingoid features. Ten patients had specific symptoms from the ectopic hormone secretion. Two had a familial syndrome. Of eight patients with excess cortisol secretion, three died as a result of the tumor resection: two had pheochromocytomas >15 cm and their associated cortisol hypersecretion complicated their postoperative course. The other died from a torn subhepatic vein. The 13 survivors did not develop any evidence of malignancy during follow-up (median 50 months). Symptoms from the ectopic secretion resolved after removal of the tumor. Immunohistochemistry was performed and was positive in eight tumors: five ACTH, three calcitonins, and one VIP. CONCLUSIONS: Most pheochromocytomas with ectopic secretion are neither malignant nor familial. Most ectopic hormone-secreting pheochromocytoma cause hypercortisolemia. Patients with a pheochromocytoma should be worked up for ectopic hormones, because removal of the pheochromocytoma resolves those symptoms. Associated cortisol secretion needs careful attention.

Wirsungostomy as a salvage procedure after pancreaticoduodenectomy.

BACKGROUND: Mortality rates associated with postoperative peritonitis or haemorrhage secondary to pancreatic fistula (PF) after pancreaticoduodenectomy (PD) remain high. This study analysed the results of an alternative management strategy for these life-threatening complications. METHODS: All patients undergoing PD between January 2004 and April 2011 were identified. Patients who underwent further laparotomy for failure of the pancreatico-digestive anastomosis were identified. Since 2004, this problem has been managed by dismantling the pancreatico-digestive anastomosis and cannulating the pancreatic duct remnant with a thin polyethylene tube (Escat tube), which is then passed through the abdominal wall. Main outcome measures were mortality, morbidity and longterm outcome. RESULTS: From January 2004 to April 2011, 244 patients underwent a PD. Postoperatively, 21 (8.6%) patients required re-laparotomy to facilitate a wirsungostomy. Two patients were transferred from another hospital with life-threatening PF after PD. Causes of re-laparotomy were haemorrhage (n= 12), peritonitis (n= 4), septic shock (n= 4) and mesenteric ischaemia (n= 1). Of the 21 patients who underwent wirsungostomy, six patients subsequently died of liver failure (n= 3), refractory septic shock (n= 2) or mesenteric ischaemia (n= 1) and nine patients suffered complications. The median length of hospital stay was 42 days (range: 34-60 days). The polyethylene tube at the pancreatic duct was removed at a median of 4 months (range: 2-11 months). Three patients developed diabetes mellitus during follow-up. CONCLUSIONS: These data suggest that preservation of the pancreatic remnant with wirsungostomy has a role in the management of patients with uncontrolled haemorrhage or peritonitis after PF.

Annular pancreas: a rare cause of acute pancreatitis.

CONTEXT: Annular pancreas is an uncommon and rarely reported congenital anomaly which consists of a ring of pancreatic tissue encircling the duodenum. Despite the congenital nature of the disease, clinical manifestations may ensue at any age. CASE REPORT: We herein report the case of a 72-year-old female with acute pancreatitis associated with duodenal obstruction. On radiologic examination, an annular pancreas was diagnosed. In view of her previous medical history and morphologic findings, we concluded that the acute pancreatitis was directly related to the congenital anomaly. Her clinical course was favorable after medical treatment. CONCLUSION: Clinicians should note the possibility of annular pancreas in patients with acute pancreatitis.

18F-FDG PET for the identification of adrenocortical carcinomas among indeterminate adrenal tumors at computed tomography scanning.

BACKGROUND: 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) has been proposed for the evaluation of adrenal tumors. However, only scarce data are available to evaluate its usefulness for the identification of primary adrenal carcinomas in patients with no previous history of cancer and equivocal tumors on computed tomography (CT) scan. The objective of the present study was to evaluate the diagnostic performance of 18F-FDG-PET to predict malignancy in such patients. METHODS AND PATIENTS: This was a retrospective study carried out from 2006 to 2009 in a single university hospital center. Twenty-three consecutive patients without previous history of cancer investigated for adrenal tumors without features of benign adrenocortical adenoma on CT scan but no obvious ACC underwent 18F-FDG PET. All patients underwent adrenalectomy because of CT scan characteristics regardless of the results of 18F-FDG PET. The ratio of maxSUV adrenal tumor on maxSUV liver (adrenal/liver maxSUV ratio) during 18F-FDG PET was compared to Weiss pathological criteria. RESULTS: Seventeen patients had an adrenal adenoma, 2 had small size adrenal carcinomas (<5 cm), 1 had an angiosarcoma, and 3 had noncortical benign lesions. An adrenal/liver maxSUV ratio above 1.6 provided 100% sensitivity, 90% specificity, and 100% negative predictive value for the diagnosis of malignant tumor. CONCLUSIONS: Because of its excellent negative predictive value, 18F-FDG-PET may be of help in avoiding unnecessary surgery in patients with non-secreting equivocal tumors at CT scanning and low 18F-FGD uptake.

Can an intraductal papillary mucinous tumor be a potential indicator of concurrent adenocarcinoma of the pancreas?

CONTEXT: Despite the recent progress of diagnostic and therapeutic modalities, survival rates of pancreatic adenocarcinoma remain poor, mainly due to late diagnosis. CASE REPORT: We report the case of a 56-year-old man who was diagnosed with a symptomatic intraductal papillary mucinous tumor of the pancreas located in the uncus. This tumor was associated with a concurrent stenosis of the isthmic pancreatic duct which resulted in a distal dilation. A Whipple procedure was performed. During the procedure, a concomitant adenocarcinoma was diagnosed 2 cm from the primary intraductal papillary mucinous tumor, causing the isthmic stenosis. A second resection was then performed to the left of the pancreatic isthmus, and adjuvant chemotherapy was performed. The patient is well and without any sign of recurrence 7 months after surgery. CONCLUSION: We discuss the possibility that intraductal papillary mucinous tumors may be a "red flag" enabling earlier diagnosis of a concurrent pancreatic adenocarcinoma arising in another area of the pancreas.

Late-night salivary cortisol for diagnosis of overt and subclinical Cushing's syndrome in hospitalized and ambulatory patients.

CONTEXT: Neither precise evaluation of pertinent thresholds nor comparison of the diagnostic performance of late-night salivary cortisol (NSC) between inpatient and outpatient settings has been conducted. The usefulness of NSC for the screening of "subclinical" Cushing's syndrome is still unknown. OBJECTIVES: The aim of the study was to compare the influence of inpatient and outpatient settings on the diagnostic performance of NSC and assess its usefulness as a screening test for subclinical Cushing's syndrome. DESIGN: Consecutive patients were investigated prospectively with two salivary collections, first as inpatients and then as outpatients. PARTICIPANTS: Forty-two obese subjects participated in the study, as well as nine patients cured of Cushing's disease, 13 with overt Cushing's syndrome, 14 showing mild recurrence of Cushing's disease, and 48 with adrenal incidentalomas [23 subclinical cortisol-secreting adenomas (SCSA), 25 nonsecreting adenomas]. MAIN OUTCOME MEASURES: Reproducibility of NSC and diagnostic performance were measured using receiver operating characteristic analysis. RESULTS: NSC in controls was similar between inpatient and outpatient settings. The diagnostic performance of NSC across the different patient groups was similar irrespective of the setting. A threshold of 12 nmol/liter yielded 100% sensitivity and specificity in overt Cushing's syndrome. Optimal performance in subclinical Cushing's syndrome required lower thresholds. NSC showed acceptable performance in diagnosing recurrence of Cushing's disease (90% sensitivity, 91.8% specificity). On the contrary, NSC was similar between patients with SCSA and nonsecreting adenomas. CONCLUSIONS: Our data validate the outpatient bed sampling strategy for NSC with no need for specific outpatient threshold. NSC may be helpful to detect mild recurrence of Cushing's disease after surgery but is of little value in identifying SCSA amongst adrenal incidentalomas.

A single-institution prospective study of laparoscopic pancreatic resection.

HYPOTHESIS: Laparoscopic pancreatic resection can safely duplicate all of the open pancreatic procedures. DESIGN: A prospective evaluation of laparoscopic pancreatic resection. Surgical procedure, postoperative course, and follow-up data were collected. SETTING: Department of Abdominal Surgery at Haut-Lévêque Hospital, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. PATIENTS: Sixty patients with presumed pancreatic neoplasms. Final diagnoses were benign disease in 57 patients (95%) and malignant pancreatic disease in 3 patients (5%). MAIN OUTCOME MEASURES: Complication and success rates of resections. RESULTS: Twenty percent of procedures were switched to open laparotomy. Laparoscopically successful procedures included 20 distal pancreatectomies with spleen preservation, 5 distal splenopancreatectomies, 16 enucleations, 5 medial pancreatectomies, 1 pancreatoduodenectomy, and 1 total pancreatectomy. Postoperative death occurred in 1 patient (1.6%). The overall postoperative complication rate was 36%, including a 13% rate of clinical fistulae. In successful laparoscopic operations, the mean (SD) postoperative hospital stay was 12.7 (6) days. Multivariate, stepwise analysis identified pancreatic consistency and pancreatic resection that required anastomosis as independent factors of postoperative complication (P = .02 and P = .002, respectively). The 3 patients operated on for pancreatic malignancies were still alive at follow-up (median, 23 months); all patients with benign disease were alive at long-term follow-up. CONCLUSIONS: This series demonstrates that laparoscopic pancreatic resection is not only feasible but also safe. Our study suggests that the best indications for a laparoscopic approach are presumably benign pancreatic tumors not requiring pancreaticoenteric reconstruction.

A second liver resection due to recurrent colorectal liver metastases.

BACKGROUND: Repeat liver resection because of recurrent colorectal liver metastases can provide survival benefit with a low rate of complications. DESIGN: Retrospective study. PARTICIPANTS: Forty patients who underwent a second hepatectomy because of liver metastases from colorectal cancer. MAIN OUTCOME MEASURES: Short- and long-term results of a second hepatectomy and determination of prognostic factors. RESULTS: The postoperative mortality rate was 2.5%. The postoperative morbidity rate was not significantly different after a second hepatectomy compared with single hepatectomy (42.5% and 27.5%, respectively; P = .10). Transfusion requirement and hospital stay were comparable for both a single and a second hepatectomy. Three- and 5-year overall survival rates were 55% and 31%, respectively. Disease-free survival rates at 3 and 5 years were, respectively, 49% and 27%. The interval between first and second hepatectomies and the presence of extrahepatic disease were independently related to survival (multivariate analysis). CONCLUSIONS: A second liver resection because of recurrent liver metastases from colorectal cancer is safe and provides a survival benefit similar to that with single hepatectomy. Our analysis suggests that the benefit of treatment is limited in patients who undergo a second hepatectomy within 1 year of the first operation and in those with extrahepatic disease.

Laparoscopic central pancreatectomy: single institution experience of 6 patients.

BACKGROUND: Medial pancreatectomy is an alternative technique for benign or low-grade malignant tumors of the neck of the pancreas. We describe our experience of laparoscopic central pancreatectomy. METHODS: We conducted a prospective evaluation of laparoscopic pancreatic resection in the Department of Abdominal Surgery at Haut-Lévêque Hospital, CHU Bordeaux. From January 1999 until February 2006, 397 patients underwent pancreatic resection for pancreatic lesions, of whom 60 (15%) were enrolled for laparoscopic pancreatic resection. Of the 60 patients, 6 underwent laparoscopic central pancreatectomy. Surgical procedure, postoperative course, and follow-up data were collected. RESULTS: Laparoscopic central pancreatectomy was successful in all patients. In 1 case, we had to perform a laparotomy to find the specimen, which had been lost in the cavity during the anastomosis. The median operative time was 225 minutes (range, 180 to 365 minutes). None of the patients required blood transfusion in the perioperative period, and there was no mortality. Symptomatic pancreatic fistula occurred in 2 patients (33%). None of the patients required reoperation or radiologic drainage. Oral feeding was resumed in a median of 11 days (range, 9 to 21 days). The median postoperative hospital stay was 18 days (range, 15 to 25 days). At a median follow-up of 15 months (range, 4 to 34 months), all patients were alive without exocrine or endocrine insufficiency. CONCLUSIONS: Laparoscopic central pancreatectomy is feasible and safe. Laparoscopic central pancreatectomy may become the standard approach for resection of benign or low-grade malignant tumors of the neck of the pancreas if performed by highly skilled surgeons.

Laparoscopic versus open approach for solitary insulinoma.

BACKGROUND: In recent years, advances in laparoscopic techniques have allowed surgeons to treat pancreatic lesions laparoscopically. Insulinoma, the most prevalent pancreatic endocrine tumor, is mostly benign and curable with surgical resection. This study aimed to assess the results from laparoscopic resection (LG) of insulinomas and to compare them with the results from open surgery (OG). METHODS: From September 1999 to December 2005, 56 laparoscopic pancreatic resections were performed for selected patients, including 12 laparoscopic resections of insulinomas. The results were compared with those of patients who underwent open resection of insulinomas selected from the authors' pancreatic database. RESULTS: Three conversions to the open approach were required because of inability to identify the tumor. There were no deaths in either group, and the morbidity rates were 25% (3/12) for LG and 55% (5/9) for OG (nonsignificant difference). The pancreatic fistula rate after laparoscopic enucleation was statistically lower than after open enucleation (14% vs 100%; p = 0.015). The mean postoperative hospital stay was 13 +/- 5.9 days for LG and 17.6 +/- 7.5 days for OG (nonsignificant difference). After exclusion of the patients who underwent conversion to laparotomy, the mean postoperative hospital stay was 11.5 +/- 5.8 days for LG and 17.6 +/- 7.5 days for OG (p = 0.04). CONCLUSION: This study demonstrates the feasibility and safety of laparoscopic resection of insulinomas. The laparoscopic approach was associated with a decrease in hospital stay and pancreatic fistula after enucleation. Preoperative localization tests and laparoscopic ultrasonography seem necessary to prevent conversion.

Subsequent resection of locally advanced pancreatic carcinoma after chemoradiotherapy.

OBJECTIVES: The aim of this study was to evaluate the possibility of subsequent resection of locally advanced pancreatic adenocarcinoma after chemotherapy and external-beam radiotherapy. PATIENTS AND METHODS: Between January 1996 and January 2001, 33 consecutive patients (18 males and 15 women, mean age 63 years) with locally advanced PA were treated with chemotherapy and concurrent external-beam radiotherapy. Radiotherapy delivered 45-50.4 Gy, in a classical manner (N=27) or on a split-course (N=6). Chemotherapy was made of 5FU by continuous infusion for all patients during 5 weeks and cisplatin at the 1st and 5th weeks (N=22). Tumor resectability was reassessed at the end of the chemoradiotherapy; surgical resection of tumour was attempted in patients whose tumor demonstrated reduction in size, and supplementary radiotherapy of 10 to 15 Gy was delivered to the others. RESULTS: Thirty-nine percent of patients experienced grade 3 acute toxicity. WHO criteria response to chemoradiotherapy four weeks after the end of treatment were: 4 partial responders (12%), 6 minor responders (18%), 14 stable disease (42%), 9 progression (28%). Ten patients underwent exploratory laparotomy, in one case vascular encasement did not allow for tumor resection, and in another patient, there was peritoneal carcinomatosis. In the 8 remaining patients, surgical (R0) resection was possible. In one patient histological examination showed fibrosis with no residual tumour. After a median follow-up period of 40 months, median survival was 16 months (66% and 37% of survival at 1 and 2 years respectively). In operated and non-operated patients, survival rates at 24 months were 73% and 12.5% respectively. At 1 year, 80% of the patients treated with radiochemotherapy developed recurrence, metastatic recurrence in 88%. Initial laparotomy, split course radiotherapy were poor outcome factors whereas chemotherapy appears to be a favorable outcome factor. CONCLUSION: Subsequent resection of locally advanced pancreatic adenocarcinoma is possible after chemoradiotherapy allowing for a prolonged survival in some patients.

Surgical resection after radiochemotherapy in patients with unresectable adenocarcinoma of the pancreas.

BACKGROUND: The use of chemoradiotherapy for pancreatic cancer has been advocated for its potential ability to downstage locally advanced tumors. This article reports our experience with chemoradiotherapy for patients with unresectable, locally advanced pancreatic cancer (superior mesenteric artery or celiac axis encasement). STUDY DESIGN: Since 1998, 61 patients with radiographically unresectable, pathologically confirmed pancreatic adenocarcinoma have received standard fractionation radiation therapy (total dose, 45 Gy at 1.8 Gy, 5 d/wk) with chemotherapy, which included a continuous infusion of fluorouracil (5-FU: 650 mg/m(2)/D1-D5 and D21-D25) and cisplatin (80 mg/m(2)/bolus D2 and D22). Patients with tumor response at restaging CT scan underwent surgical exploration to determine whether the tumor was resectable. RESULTS: Thirty-eight of 61 (62%) restaged patients demonstrated a disease progression. Twenty-three patients (38%) had an objective response, with, in all cases, persistence of arterial encasement. Twenty-three patients underwent exploratory operations after chemoradiotherapy, and 13 underwent standard Whipple resection. So 13 of 23 (56%) patients who had exploratory operation, or 23 of 61 (21%) patients, underwent surgical resection. With a median followup of 27 months, median survival for the resected patients was 28 months. Median survival was 11 months in the nonresponder group (n = 38) and 20 months in the group who received a palliative procedure (n = 10). CONCLUSIONS: Locally advanced, unresectable pancreatic adenocarcinoma may be downstaged by chemoradiotherapy to allow for surgical resection. Patients whose cancer becomes resectable have a median survival at least comparable with survival after resection for initially resectable pancreatic adenocarcinoma.

Pancreaticojejunal anastomosis is preferable to pancreaticogastrostomy after pancreaticoduodenectomy for longterm outcomes of pancreatic exocrine function.

BACKGROUND: The aim of this study was to evaluate pancreatic exocrine and endocrine function after pancreaticoduodenectomy. STUDY DESIGN: Pancreatic exocrine function was evaluated by a questionnaire and medical examination of stools after discontinuing pancreatic enzyme supplements for at least 10 days. Severe steatorrhea was defined as frequent, nauseating, yellow, and pasty stools, fecal output >200 g/d for more than 3 days. Endocrine function was evaluated by blood glucose level. Association between severe steatorrhea and age, indication, histologic obstructive pancreatitis, pancreaticojejunal anastomosis (PJA), pancreaticogastric anastomosis (PGA), and morbidity was studied. RESULTS: Fifty-two patients underwent pancreaticoduodenectomy, complication rate was 33%. PJA was performed in 41 patients (79%) and PGA in 11 patients (21%). At a median followup of 75 months (24 to 156 months), 65% of the patients received pancreatic enzyme supplements. Severe steatorrhea was observed in 22 patients (42%). Incidence of postoperative diabetes was 14.6%. Patient age (more than 60 years), postoperative complication, and obstructive pancreatitis were not associated with postoperative severe steatorrhea. In cases of nonhistologic obstructive pancreatitis, PGA was more frequently associated with severe steatorrhea than PJA (70% versus 21.7%, p < 0.025). No factor significantly influenced incidence of postoperative diabetes. CONCLUSIONS: After pancreaticoduodenectomy, 42% of patients presented with severe steatorrhea. PJA allows better pancreatic exocrine function preservation than PGA and should be recommended.