Neoadjuvant immunotherapy in microsatellite instability-high (MSI-H) duodenal adenocarcinoma leads to pathological complete response and paves the way for new strategies

Duodenal adenocarcinoma is a rare digestive cancer, often diagnosed at a late stage and harbours a poor prognosis. The arrival of immunotherapy has changed the prognosis of many neoplasia, including digestive adenocarcinomas with MSI-H status. Hereby, we describe three cases of MSI-H locally advanced duodenal adenocarcinoma who received neoadjuvant treatment with a PD1 inhibitor, pembrolizumab. A partial metabolic and endoscopic response was observed in all patients after 2 cycles. Duodenopancreatectomy was performed at the end of treatment (4-6 cycles), and anatomopathological analysis demonstrated pathological complete response in all patients. Our case series paves the way for prospectively exploring neoadjuvant immunotherapy in duodenal MSI-H adenocarcinoma and raises the question of organ sparing surgery in case of complete clinical response as observed in gastric and colo-rectal adenocarcinomas.

Pulmonary hemodaynamic in obesity

Background

Higher prevalence of pulmonary hypertension exist in obesity subjects. Little known about pulmonary hemodynamics during exercise in obesity population.

Purpose

To assess and compare the response of pulmonary vascular resistance during exercise in obese subjects vs healthy controls.

Methods

Seventeen obesity subjects (gender: 25%men, age: 44±11 years, height: 1.7±0.1 m, weight: 111±17 kilogram, BMI: 38±4 kg/m2) were compared to twenty gender-, age-, height- and race-matched healthy control subjects (age: 46±12 years, height: 1.7±0.1 m, weight: 64±11 kilogram, BMI: 22±2 kg/m2). All subjects underwent an incremental exercise stress echocardiography with measurements of pulmonary artery pressure (PAP), cardiac output (CO), cardiac index (CI) and tricuspid annular plane systolic excursion (TAPSE) at rest and at increasing exercise intensities. Total pulmonary vascular resistance index (PVRi) was calculated as mean PAP/CI and right ventricular-arterial coupling as TAPSE/systolic PAP.

Results

The results are described in the table 1. Pulmonary hemodynamic was not different at rest between two groups, but lower at maximal exercise in obesity subjects. In obesity subjects, identical exercise level was associated with a higher mean PAP and PVRi, and a lower TAPSE/systolic PAP ratio.

Conclusion

While pulmonary hemodynamic seems preserved at rest in obesity patients, pulmonary vascular resistance is increased and right ventricular coupling is decreased, particularly at exercise.

Funding Acknowledgement

Type of funding source: None

Assessment of the optimal timing for early laparoscopic cholecystectomy in acute cholecystitis: a prospective study of the Club Coelio

Background: The optimal timing for cholecystectomy in patients with acute cholecystitis remains controversial. The aim of this study is to assess prospectively the impact of the duration of symptoms on outcomes in early laparoscopic cholecystectomy (ELC) for acute cholecystitis. Methods: The series consisted of 276 consecutive patients who underwent ELC for acute cholecystitis in 2016. The patients were divided into three groups according to the timing of surgery: within the first 3 days (group 1), between 4 and 7 days (group 2) and beyond 7 days (group 3) from the onset of symptoms. Results: The percentage of surgical procedure rated as difficult was respectively: 12% in G1, 18% in G2 and 38% in G3 (p < .001). Accordingly, we observed an increased mean operative time within groups but no significant difference in the conversion rate. We noted a different overall postoperative complication rate within groups, respectively: 9% in G1, 14% in G2 and 24% in G3 (p < .04). The median hospital stay was also different within groups, respectively: 3 in G1, 4 in G2 and 6 days in G3 (p < .001). On univariate analysis, age ≥60, male gender, ASA 3, WBC ≥13.000/µL, CRP ≥100 mg/l and delay between onset of symptoms and surgery were factors statistically associated with increased morbidity rate. On multivariate analysis, the delay was the only independent predictive factor of postoperative morbidity (OR: 1,08, 95% CI: 1.01-1.61, p < .031). Conclusion: Our study confirms that it is ideal to perform ELC within 3 days of symptoms onset and reasonable between 4 to 7 days. We do not recommend performing ELC beyond 7 days because of more difficult procedure and significantly increased risk of post-operative complications.

Risk factors of perioperative morbimortality after laparoscopic sleeve gastrectomy: a club coelio multicenter study

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.

Laparoscopy-assisted transjejunal ERCP in a patient with roux-en-Y gastric bypass

In the case of Roux-en-Y gastric bypass with a long afferent limb, the need to carry out an ERCP still represents a technical challenge. In this article we describe the case of a 50-year-old male admitted to the ER for abdominal pain in the right upper quadrant, in the context of prior Roux-en-Y gastric bypass (4 years ago), with uncomplicated gallbladder stones discovered 3 months ago. The patient presented recurrent abdominal pain for 3 months but in the last few days the pain became continuous. The blood test revealed elevation of hepatic enzymes and bilirubin levels. The US findings were uncomplicated gallbladder lithiasis with no signs of lithiasic migration in the common bile duct, despite strong clinical suspicion and positive MRI 3 weeks before. We decided therefore to perform a laparoscopic cholecystectomy with perioperative cholangiography and a laparoscopy-assisted transjejunal ERCP through a jejunostomy 80 cm distal to the ligament of Treitz, allowed us to successfully carry out sphincterotomy and extraction of a 10mm lithiasis from the common bile duct.

Gastric Bypass for Morbid Obesity in a Patient with Situs Inversus Totalis

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.

Gastric bypass for morbid obesity in a patient with situs inversus totalis

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.

Previous bariatric surgery increases postoperative morbidity after sleeve gastrectomy for morbid obesity

OBJECTIVES

Sleeve gastrectomy (SG) has been used as the first step of a staged malabsorptive procedure for high-risk patients. More recently SG was proposed as an stand alone procedure in the treatment of morbidly obese patients. The aim of this study is to analyze perioperative outcome of morbid obese patients after SG.

METHODS

301 patients, 201 women and 100 men, undergoing SG were retrospectively analyzed. SG was performed by 17 surgeons all member of the Club Coelio. The mean BMI was 44.7kg/m2 (27.4-70.3 kg/m2). 34 patients (11.3%) of our series had SG as revisional surgery. These revisional procedures consisted of 32 conversions from gastric banding, 1 conversion from vertical gastroplasty (VBG) and 1 from transoral endoscopic gastroplasty. Among the 32 patients that had revisional SG after a gastric banding, 13 bands were removed at least 3 months before the revisional SG and 19 bands were removed during the SG procedure. Endpoints were perioperative morbidity and mortality and potential risk factors for complications, mainly per or postoperative bleeding or leakage.

RESULTS

Overall mortality was 0% and morbidity was 10.3%. Perioperative bleeding occurred in 10 patients (3.3%), leakage in 12 patients (4%) patients and stenosis in 3 patients (1%). The risk of leakage was significantly higher after revisional bariatric surgery and in case of gastric perforation during surgery (p = 0.0001). Previous gastric banding is also associated with a higher risk of postoperative bleeding (p = 0.0006).

CONCLUSIONS

SG can be safely performed but patients and surgeons must be aware of a higher risk of postoperative complications when SG is proposed as a revisional surgery.

Contribution of CXCR4 and SMAD4 in predicting disease progression pattern and benefit from adjuvant chemotherapy in resected pancreatic adenocarcinoma

BACKGROUND

Prognosis of patients with pancreatic adenocarcinoma is poor. Many prognostic biomarkers have been tested, but most studies included heterogeneous patients. We aimed to investigate the prognostic and/or predictive values of four relevant biomarkers in a multicentric cohort of patients.

PATIENTS AND METHODS

A total of 471 patients who had resected pancreatic adenocarcinoma were included. Using tissue microarray, we assessed the relationship of biomarker expressions with the overall survival: Smad4, type II TGF-β receptor, CXCR4, and LKB1.

RESULTS

High CXCR4 expression was found to be the only independent negative prognostic biomarker [hazard ratio (HR) = 1.74; P < 0.0001]. In addition, it was significantly associated with a distant relapse pattern (HR = 2.19; P < 0.0001) and was the strongest prognostic factor compared with clinicopathological factors. In patients who did not received adjuvant treatment, there was a trend toward decrease in the overall survival for negative Smad4 expression. Loss of Smad4 expression was not correlated with recurrence pattern but was shown to be predictive for adjuvant chemotherapy (CT) benefit (HR = 0.59; P = 0.002).

CONCLUSIONS

CXCR4 is a strong independent prognostic biomarker associated with distant metastatic recurrence and appears as an attractive target to be evaluated in pancreatic adenocarcinoma. Negative SMAD4 expression should be considered as a potential predictor of adjuvant CT benefit.

[Gastric adenocarcinoma following "silastic vertical ring gastroplasty": case report]

OBJECTIVES

Bariatric surgery is considered as the most effective therapy for morbid obesity. But, each procedure carries both short-and long-term complications. And, it remains unclear if the late occurrence of gastric adenocarcinoma could be linked to bariatric surgery. We described a case of a female who developed a gastric adenocarcinoma after a silastic ring vertical gastroplasty (SRVG).

METHODS

A 54-year-old female presented with postprandial vomiting, poor appetite, dysphagia and weight loss 10 year after a SRVG. A gastroscopy with biopsy disclosed a juxta-pyloric adenocarcinoma. No distant metastasis was found. After 3 cycles of neoadjuvant chemotherapy, a subtotal gastrectomy with Roux-en-Y anastomosis was performed.

RESULTS

After the surgery, a minor anastomotic leak was treated conservatively and a parietal abscess was drained. The pathological studies demonstrated a T2bN1 adenocarcinoma with negative margins. Adjuvant chemotherapy was administered. At the last work up, the patient is disease-free.

CONCLUSION

The association between a gastric adenocarcinoma and a bariatric procedure such as a SRVG is difficult to assess without a case-control or a cross-sectional study. Nevertheless, when new upper digestive tract complaints occur in any patient with an otherwise unremarkable bariatric surgery follow-up, the diagnosis of gastric cancer should be bear in mind.

Transoral gastroplasty is safe, feasible, and induces significant weight loss in morbidly obese patients: results of the second human pilot study

BACKGROUND AND STUDY AIMS

Bariatric surgical treatments have been proven to induce long-term weight loss in morbidly obese patients, but complications are relatively frequent. We recently reported a first human multicenter trial assessing the safety, feasibility, and weight loss results of the Transoral Gastroplasty (TOGA) system (Satiety Inc., Palo Alto, CA) at 6 months. Here we report the 6-month results of the second phase of the pilot trial with the TOGA system, with technical improvements to the device.

PATIENTS AND METHODS

Patients met established criteria for bariatric surgery. The TOGA system, a set of transoral endoscopically guided staplers, was used to create a stapled restrictive pouch along the lesser curvature of the stomach. Follow-up was at 1 week and at 1, 3, and 6 months. At 3 months, re-treatment consisting in additional distal restrictions was allowed if necessary.

RESULTS

Data were available for 11 patients in our center (7 female, mean age 44.2 years, mean body mass index 41.6). The procedure was completed safely in all patients. There were no serious adverse events. Mean excess weight loss was 19.2 %, 33.7 %, and 46.0 % at 1, 3, and 6 months, respectively. Average body mass index decreased from 41.6 before treatment to 33.1 at 6 months. Absolute mean weight loss was 9.9 kg, 17.5 kg, and 24.0 kg at 1, 3, and 6 months, respectively. A dramatic improvement in quality-of-life measures was observed in all patients.

CONCLUSIONS

This second pilot trial confirmed the feasibility and safety of transoral gastroplasty. The early results and technical improvements reported in the present study are encouraging in terms of safety, early weight loss, and quality of life, and clearly allowed multicenter trials, which are planned to start soon.

Nissen versus Toupet fundoplication: results of a randomized and multicenter trial

BACKGROUND

Laparoscopic Toupet fundoplication (TF) is reported to be as effective as Nissen (NF), but to be associated with fewer unfavorable postoperative side-effects. This study evaluates the one- and three-year clinical outcome of 140 randomized patients after a laparoscopic NF or TF.

PATIENTS AND METHODS

Inclusion criteria included patients over 16 years old with complications of gastro-oesophageal reflux disease (GORD) and persistence or recurrence of symptoms after three months of treatment. Subjects with a previous history of gastric surgery or repeated fundoplication, brachy-oesophagus or severe abnormal manometry results were excluded. Seventy-seven NF and 63 TF were performed. The severity of symptoms was assessed before and after the procedure.

RESULTS

One hundred and twenty-one of the 140 patients after one year, and 118 after three years, were evaluated and no statistically significant clinical difference was observed. The level of satisfaction concerning the outcome of the operation remained high after one or three years regardless of the type of fundoplication performed.

CONCLUSIONS

Functional complications after NF are not avoided with TF.

Safety, feasibility and weight loss after transoral gastroplasty: First human multicenter study

OBJECTIVE

To evaluate the safety and feasibility in human subjects of a new transoral restrictive procedure for the treatment of obesity.

METHODS

The protocol was approved by the institutional review boards (IRBs) of both centers involved, and all patients gave informed consent. Patients met established inclusion criteria for bariatric surgery. The TOGa system (Satiety Inc., Palo Alto, CA), a set of transoral endoscopically guided staplers, was used to create a stapled restrictive pouch along the lesser curve of the stomach. Patients were hospitalized overnight for observation and underwent barium upper gastrointestinal (UGI) the next morning. Post procedure, all patients were placed on a liquid diet for 1 month and asked to begin an exercise program. Follow-up was carried out at 1 week and 1, 3, 4, 5, and 6 months.

RESULTS

Twenty one patients were enrolled [17 female, age 43.7 (22-57) years, BMI 43.3 (35-53) kg/m(2)]. Device introduction was completed safely in all patients. There were no serious adverse events (AEs). The most commonly reported procedure or device related adverse events were vomiting, pain, nausea, and transient dysphagia. At 6 month endoscopy, all patients had persistent full or partial stapled sleeves. Gaps in the staple line were evident in 13 patients. Patients lost an average 17.6 pounds at 1 month, 24.5 pounds at three months, and 26.5 pounds at 6 months post-treatment [excess weight loss (EWL) of 16.2%, 22.6%, and 24.4%, respectively].

CONCLUSIONS

There is great interest in new procedures for morbid obesity that could offer lower morbidity than current options. Early experience with the TOGa procedure indicates that this transoral approach may be safe and feasible. Further experience with the device and technique should improve anatomic and functional outcomes in the future. Additional studies are underway.

[Bariatric surgery: which patient for which type of surgery?]

Bariatric surgery remains the only durable option for weight loss in the morbidly obese patient. The aim of this article is to present the different types of surgical procedures. This multidisciplinary approach try to define which type of surgery would be the more indicated for which patient.

Results of silastic ring vertical gastroplasty more than 6 years after surgery: analysis of a cohort of 214 patients

BACKGROUND

Among the different techniques of surgical treatment for morbid obesity, silastic ring vertical gastroplasty (SRVG) is an alternative, effective and easily reproducible technique. The aim of this study is to evaluate a cohort of patients >6 years after SRVG for morbid obesity.

METHODS

From 1991 to 1996, 273 consecutive patients were eligible for SRVG. The evaluation criteria included weight loss, evolution of co-morbidities, long-term morbidities, satisfaction of patients and quality of life.

RESULTS

Among these 273 patients, 1 patient died in the postoperative period (0.4%). Postoperative morbidities occured in 27 patients (10%). The long-term follow-up involved 213 patients (78%). Late postoperative complications consisted of outlet stoma stenosis (14%), staple-line dehiscence (5.6%) and incisional hernia (8.5%). 23 patients (10%) needed a re-do operation. Co-morbidities drastically improved. BMI fell from 45.3 to 30.7. Failure of SRVG was statistically associated with male gender and super-obese patients. 69% of the patients were satisfied, and 73% would recommend this operation.

CONCLUSION

SRVG is very effective in a selected group of morbidly obese patients.

Laparoscopic Nissen fundoplication after failure of Enteryx injection into the lower esophageal sphincter

BACKGROUND

We investigated the feasibility, safety, and efficacy of laparoscopic antireflux surgery (LARS) after failure of Enteryx injection in the lower esophageal sphincter for the treatment of gastroesophageal reflux disease (GERD).

METHODS

Four patients underwent LARS after failure of Enteryx injection. Particular care was taken during the procedure to identify unusual material or fibrosis.

RESULTS

All patients underwent LARS successfully. In three patients, tight adhesions with fibrous tissues and black foreign material were observed around the esophagus. No complications occurred during the procedures. The postoperative period was uneventful and functional results were excellent.

CONCLUSION

LARS following Enteryx injection is feasible. Careful dissection is mandatory to avoid operative complications. Both techniques may be considered as options for treating GERD.

Right hepatic artery pseudoaneurysm and cystic duct leak after laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) seems to be associated with an increased risk of biliary or vascular injuries. Hepatic artery pseudoaneurysms (HAP) are rare complications of LC. HAP can occur in the early or late postoperative period. Patients with HAP present with abdominal pain, hemobilia, and liver function test (LFT) alterations. We report the case of a patient who was affected with a cystic duct stump leak associated with a right HAP and was treated by endoscopic biliary drainage and angiographic coil embolization.

Delayed gastric emptying after pancreatoduodenectomy

With pylorus-preserving pancreatoduodenectomy (PPPD) the goal is to reduce long-term morbidities such as gastric dumping, marginal ulceration or bile-reflux gastritis. Compared with te classical Whipple procedure, PPPD is affected by an equal postoperative morbidity but is known to induce delayed gastric emptying (DGE). It is difficult to evaluate the true incidence of DGE after PPPD (from 5 to 50% according to the literature). Early and low doses of erythromycin in the postoperative period could prevent the onset of DGE and the administration of cisapride 15 mg/day improves gastric emptying up to 6 months after PPPD.

[The surgical gastroenterology department]

The Department of Digestive Surgery was born in 1977. It is a part of the medical surgical unit of gastroenterology and hepatopancreatology. The various developed sectors concern hepatic surgery and liver transplantation (treatment of hepatic tumors and cirrhosis), pancreatic surgery and surgery of the biliary tract (treatment of benign and malignant pancreatic tumors, tumor of the biliary tract, chronic pancreatitis and biliary stones), surgery of morbid obesity (gastroplasty or gastric by-pass), surgery of the upper digestive tract (benign and malignant tumors of the oesophagus or the stomach, treatment of gastroesophageal reflux), surgery of the abdominal wall, colorectal surgery and surgery of the inflammatory bowel diseases (colorectal cancer, familial polyposis, Crohn's disease, ulcerative colitis), proctologic surgery and surgery of anorectal functional disorders, neonatal and paediatric surgery.