ABSTRACTWe report on a 31‐year‐old male patient diagnosed with active moderate‐to‐severe ulcerative colitis and a history of splenectomy. He was hospitalized due to confluent pustular oral lesions and multiple skin abscesses. After ruling out an infection, we diagnosed pyostomatitis vegetans associated with aseptic abscess syndrome. After multiple unsuccessful treatments (corticosteroids, infliximab, ciclosporin, ustekinumab and colectomy), filgotinib, a JAK 1 inhibitor, was then initiated, resulting in the complete resolution of skin lesions.

Background: In colon cancer (CC), surgery remains the mainstay of treatment with curative intent. Despite several clinical trials comparing open and laparoscopic approaches, data on long-term outcomes for stage III CC are lacking. Methods: This post-hoc analysis of the European PETACC8 randomized phase 3 trial included patients from 340 sites between December 2005 and November 2009, with long follow-up (median 7.56 years). Patients were randomly assigned to FOLFOX or FOLFOX + cetuximab after colonic resection. The surgical approach was left to the referring surgeon's discretion. Results: Among 2555 patients included, 1796 (70.29%) were operated on by open surgery and 759 (29.71%) by laparoscopy. The 5-year OS rate was better after laparoscopic resection (85.4%, 95%CI 82.5- 87.7) than after open surgery (80.2%, 95%CI 78.2-82.0; p = 0.002). The 5-year DFS rate was also better after laparoscopy ( p = 0.016). However, in multivariate analysis using a propensity matching, the surgical approach was not found to be an independent prognostic factor for OS or DFS. OS ( p = 0.0243) and DFS ( p = 0.035) were increased after laparoscopic surgery in KRAS/BRAF WT sub-group Conclusion: We showed that laparoscopic resection has comparable long-term outcomes to open surgery in patients with stage III CC. For those with RAS and BRAF WT CC, laparoscopic colectomy may favorably impact survival. (c) 2021 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Abstract Background The current recommendations remain vague as to whether biologics are safe or deleterious when surgery is contemplated in patients with Crohn’s disease (CD). Conflicting data do not enable to adopt a definitive position on the time to surgery. The aims of this study were to evaluate the impact of perioperative treatments on the rate of surgical complications and to report surgical recurrence rate of CD after ileo-caecal (IC) resection. Methods This was a retrospective monocentric cohort study of consecutive CD patients who underwent IC resection between 1996 and 2018. An ethical committee has been approved (P2019/376). The overall rate of surgical complications was evaluated within 30 days after surgery. The effect of pre- and postoperative treatments was assessed on overall morbidity, general and infectious complications, anastomotic leakage and risk factors. Statistical analyses were performed using SPSS. Results Demographic data of the 165 CD patients who underwent a primary IC resection are presented in Table 1. The median age at time of the first IC resection was 35 years (IQR 24–44) while the median follow-up was 6.1 years (IQR 1–11). The overall rate of complications was 18% including 8.7% and 3.3% patients with infectious complications and anastomotic leakage, respectively. No risk factors have been found to be associated with surgical complications. In particular, immunosuppressants and biologics did not increase the risk of surgical complications. Twenty-four per cent of patients (n = 39/160) needed a second IC resection due to stenosis at the anastomosis site in 69.2% of cases (n = 27/39). Surgical recurrence was found to increase linearly over time with a second surgery after a median follow-up of 8 years (IQR 2–12). Anti-TNF used as post-operative treatment had a protective role on surgical recurrence in multivariable regression with odd ration (OR) of 0.15, p = 0.001 (Table 2). Conclusion Prevalence of complications after an IC resection in CD patients was of 18% in this retrospective monocentric cohort. No risk factors were found to be associated with surgical complications. Anti-TNF seems to have a protective role on surgical recurrence.

Background Recurrence patterns in stage III colon cancer (CC) patients according to molecular markers remain unclear. The objective of the study was to assess recurrence patterns according to microsatellite instability (MSI), RAS and BRAF V600E status in stage III CC patients. Methods All stage III CC patients from the PETACC-8 randomized trial tested for MSI, RAS and BRAF V600E status were included. The site and characteristics of recurrence were analyzed according to molecular status. Survival after recurrence (SAR) was analyzed. Results A total of 1650 patients were included. Recurrence occurred in 434 patients (26.3%). Microsatellite stable (MSS) patients had a significantly higher recurrence rate (27.2% vs. 18.7%, P = 0.02) with a trend to more pulmonary recurrence (28.8% vs. 12.9%, P = 0.06) when compared to MSI patients. MSI patients experienced more regional lymph nodes compared to MSS (12.9% vs. 4%, P = 0.046). In the MSS population, the recurrence rate was significantly higher in RAS (32.2%) or BRAF (32.3%) patients when compared to double wild-type patients (19.9%) ( p < 0.001); no preferential site of recurrence was observed according to RAS and BRAF V600E mutations. Finally, decreased SAR was observed in the case of peritoneal recurrence or more than two recurrence sites. Conclusions Microsatellite, RAS and BRAF V600E status influences recurrence rates in stage III CC patients. However, only microsatellite status seems to be associated with specific recurrence patterns. More than two recurrence sites and recurrence in the peritoneum were associated with poorer SAR.

La FAPA (association belge pour la polypose adénomateuse familiale) a été créée en 1993 dans le but d’enregistrer les patients atteints de polypose adénomateuse familiale (FAP) Les données de tous les patients inclus de manière prospective dans le registre belge FAPA entre 1993 et 2018 ont été analysées. Il y avait 442 patients de 199 familles avec un âge médian de 47 (2–88) et un âge médian au diagnostic de 23,5 (1–69) au moment du diagnostic. Un nombre médian de 1 (1–7) tumeurs desmoïdes, principalement intra-abdominales, étaient présentes chez 78 patients (18 %). Un cancer du tractus gastro-intestinal supérieur a été diagnostiqué à l’âge médian de 57 (22 à 83) ans chez 36 (8,1 %) des patients. Un cancer colorectal a été diagnostiqué chez 100 patients (22,6 %) à un âge médian de 43,5 ans (15 à 72 ans) et était réparti entre 62/159 (39 %) probands versus 38/283 (13 %) patients dépistés (p < 0,001). La survie brute cumulative était de 87 % chez les patients dépistés comparée à 79 % chez les probands (p = 0,0209). Une comparaison de deux périodes de diagnostic, avant et après 1990, a montré une prévalence réduite du cancer colorectal de 24 % à 22 % (p = 0,0003). Une coloproctectomie totale (CPT) a été réalisée chez 204 patients (52 %) et une colectomie totale avec anastomose iléo-rectale (AIR) chez 148 (38 %). Parmi ces derniers, 22 % ont bénéficiés d’une proctectomie complémentaire. Depuis la création du registre belge de la polypose, l’enregistrement centralisé avec identification et examen prophylactique des apparentés à risque a permis une amélioration substantielle du pronostic.

The purpose of this study was to assess the effects of using a real time clinical decision-support system, "Assisted Fluid Management" (AFM), to guide goal-directed fluid therapy (GDFT) during major abdominal surgery. We compared a group of patients managed using the AFM system with a historical cohort of patients (control group) who had been managed using a manual GDFT strategy. Adherence to the protocol was defined as the relative intraoperative time spent with a stroke volume variation (SVV) < 13%. We hypothesised that patients in the AFM group would have more time during surgery with a SVV < 13% compared to the control group. All patients had a radial arterial line connected to a pulse contour analysis monitor and received a 2 ml/kg/h maintenance crystalloid infusion. Additional 250 ml crystalloid boluses were administered whenever measured SVV ≥ 13% in the control group, and when the software suggested a fluid bolus in the AFM group. We compared 46 AFM-guided patients to 38 controls. Patients in the AFM group spent significantly more time during surgery with a SVV < 13% compared to the control group (median 92% [82, 96] vs. 76% [54, 86]; P < 0.0005), and received less fluid overall (1775 ml [1225, 2425] vs. 2350 ml [1825, 3250]; P = 0.010). The incidence of postoperative complications was comparable in the two groups. Implementation of a decision support system for GDFT guidance resulted in a significantly longer period during surgery with a SVV < 13% with a reduced total amount of fluid administered. Trial registration: Clinical Trials.gov (NCT03141411).

Background: Deep infiltrating endometriosis (DIE) of the large bowel is infiltration of the large-bowel wall by endometrial-like implants and is associated with fibrosis and muscular hyperplasia. Deep endometriosis affects similar to 20% of patients with endometriosis. Objective: The aim of this research was to assess the importance of anastomotic stricture (AS) after large-bowel resection for DIE of the colon. Materials and Methods: This was a retrospective analysis of prospectively collected data. A consecutive series of 113 colonic resections for DIE were performed to address pain and/or infertility. There were low and very-low resections (n = 82) with mechanical end-to-end anastomosis associated with or without partial colpectomy, segmental sigmoid resections with side-to-end anastomosis (n = 27), and ileocecal resections with latero-lateral anastomosis (n = 4). Pneumatic balloon dilatation was performed in cases of AS (n = 22 in 13 patients). Patients were asked preoperatively and at 4, 8, 12, and 24 months postoperatively, about symptoms of constipation, small-caliber stools, and abdominal bloating. Patients presenting with those symptoms underwent double-contrast barium enema. When the smallest diameter of the suture was < 12 mm in the anteroposterior or profile positions, diagnostic and therapeutic rectosigmoidoscopy was performed. Pneumatic dilatation was performed in patients with AS, until they were symptom-free. Mean operating time, age, body mass index, follow-up, length of the large-bowel resection, and largest diameter of the lesion on the colon were compared between a group with confirmed symptomatic AS and a group without AS or without suspicion of AS. Statistical analysis was performed with a two-tailed Student's t-test. Results: Thirteen patients (12%) had AS and underwent dilatation. The mean diameter of AS was 8.6 +/- 1mm and the final diameter after dilatation was 14.3 +/- 3.1 mm. The mean distance between AS and anal verge was 8 +/- 2 cm. The mean delay of occurrence of symptoms of AS was 7.8 +/- 1.2 weeks. The total number of dilatations was 22.38% of patients with confirmed AS who underwent a second dilatation. AS occurred only after low or very low rectal resections associated with colpectomy and mechanical end-to-end anastomosis. All patients with AS (n = 13) were symptom-free after one or several dilatations. No difference was found between the AS group and the group without AS or without suspicion of AS. Conclusions: AS seems to be a frequent complication after low or very low rectal resections associated with posterior colpectomy and mechanical end-to-end anastomosis. AS may require several dilatations. It occurs mainly after low or very low rectal resections. Long-term good results can be achieved with endoscopic balloon dilatation. Surgeons should be aware of this potential complication and inform patients clearly before performing operations. Further comparative studies based on this specific complication are necessary before drawing definitive conclusions about prevention and the most adequate treatments.

Optimising the management of hospitalised patients is a major concern. In colorectal surgery, the concept of enhanced recovery has been popularised by means of “fast-track” protocols, aiming at patient's discharge on the second postoperative day. Nevertheless, a strict fast-track protocol has several limitations. It is very demanding for the patient and therefore applicable only to a limited number of patients.

3610 Background: Although being the standard-of-care for stage III colon cancer, no biomarkers can identify patients (pts) who benefit from adjuvant chemotherapy. In metastatic pts, the lack of metabolic response (mR) in FDG-PET/CT after 1 chemotherapy cycle predicts the absence of treatment benefit. The PePiTA study aims to evaluate if the absence of mR after 1 cycle of pre-operative chemotherapy is predictive of recurrence in non-metastatic colon cancer pts. Herein, we report a preliminary analysis on surgical outcomes, adverse events and mR assessment after 1 cycle of pre-operative chemotherapy after completing the study accrual objective. Methods: Colon cancer pts eligible for curative resection and ECOG ≤1 received 1 cycle of mFOLFOX followed by surgery in this prospective, multicentre, non-randomized trial. FDG-PET/CT was performed at baseline and after 1 cycle of mFOLFOX. Adjuvant mFOLFOX was administered for up to 12 cycles for stage III pts, whereas for stage II pts the decision to pursue adjuvant chemotherapy was at investigator’s discretion. A decrease ≥15% in SUVmax after 1 cycle of chemotherapy was defined as mR (EORTC criteria) at central review. Results: mR was assessable on the primary tumor in 204/240 pts (85%). In 11 pts (4.6%), staging was modified by the baseline FDG-PET/CT, which detected metastatic disease or other tumors. Pre-operative mFOLFOX was administered to 218 pts, of which 14 (6%) had a grade ≥3 adverse event. Surgery was performed in 218 pts, with a median delay of 20 days (6 to 59) after chemotherapy. Surgical complications occurred in 28 (13%) pts, however no deaths occurred. The median SUVmax decrease between baseline and 2nd FDG-PET/CT was 24%. A mR was observed in 65.2% of the pts, whereas 34.8% showed no mR, including 3% who had progressive disease. Conclusions: One cycle of pre-operative mFOLFOX followed by a mR assessment has shown to be a feasible and safe strategy, raising interest on the potential of neoadjuvant chemotherapy in colon cancer. The early mR assessment identified pts that may not benefit from chemotherapy and might have a worse prognosis. The substantiation of this hypothesis is expected with the study’s long-term results. Clinical trial information: NCT00994864.

Gastric endometriosis is a very rare event. It enters in the differential diagnosis of cyclical or chronic epigastric pain, especially in the context of endometriotic patients. The diagnosis of a gastric submucosal mass requires further investigations to rule out the presence of malignancy or associated adenocarcinoma. Because of it can be associated with transverse colon endometriosis and/or diaphragmatic endometriosis, careful examination of the upper abdomen at laparoscopy should be emphasized. We report here a very rare case of gastric endometriosis associated with transverse colon endometriosis.

Aim A modification is described of the J-pouch to facilitate ileoanal anastomosis in the presence of an anal or anovaginal fistula.Method The bowel is divided at the level of the apex of the J-pouch, the distal limb is advanced to project beyond the proximal limb by 3-5 cm. The pouch is constructed by a side-to-side anastomosis to form the H-pouch with a distal ileal segment, which is passed through the anal canal to form an ileoanal anastomosis.Results The modification allows the treatment of anal and rectal disorders not resolvable by a usual J-pouch construction, as in cases where a rectal resection is needed for concomitant fistulation or destruction of the anal mucosa. The functional results are similar to those of the J-pouch, with no added postoperative morbidity. This technique helps to avoid permanent stoma in selected cases.Conclusion The modified pouch is relatively simple to perform and can help the surgeon to address complex anorectal disorders.

BACKGROUND:We report on a pilot study investigating the feasibility of early immunosuppression withdrawal after liver transplantation (LT) using antithymocyte globulin (ATG) induction and rapamycin. METHODS:LT recipients received 3.75 mg/kg per day ATG from days 0 to 5 followed by rapamycin-based immunosuppression. In the absence of acute rejection (AR), rapamycin was withdrawn after month 4. Immunomonitoring included analysis of peripheral T-cell phenotypes and clonality, cytokine production in mixed lymphocyte reaction, and characterization of intragraft infiltrating cells. RESULTS:Ten patients were enrolled between October 2009 and July 2010. In the first three patients, complete withdrawal of immunosuppression after month 4 led to AR. No further withdrawals of immunosuppressive were attempted. Two AR occurred in the remaining seven patients. ATG induced profound T-cell depletion followed by CD8(+) T-cell reexpansion exhibiting memory/effector-like phenotype associated with progressive oligoclonal T-cell expansion (Vβ/HPRT ratio) and gradually enhanced anti-cytomegalovirus and anti-Epstein-Barr virus T-cell frequencies. Patients developing AR were characterized by decreased TCAIM expression. AR were associated with increased donor-specific production of interferon (IFN)-γ and interleukin (IL)-17, increased intragraft expression of IFN-γ mRNA, and significant CD8(+) T-cell infiltrates colocalizing with IL-17(+) cells. CONCLUSION:High-dose ATG followed by short-term rapamycin treatment failed to promote early operational tolerance to LT. AR correlates with expansion of memory-type CD8(+) T cells and increased levels of IFN-γ and IL-17 in mixed lymphocyte reaction and in the graft. This suggests that resistance and preferential expansion of effector memory T-cell in lymphopenic environment could represent the major barrier for establishment of tolerance to LT in approaches using T-cell-depleting induction.

The treatment of hepatocellular carcinoma (HCC) in cirrhotic patients is challenging : the incidence is increasing, the cirrhosis dramatically limits the tolerance to treatment possibilities, there are many therapeutic modalities but resources are limited, namely in the context of organ shortage for transplantation. Liver transplantation (LT) is the optimal treatment as it combines the largest tumor resection possible and the correction of the underlying liver disease. Due to organ shortage however, LT is reserved for early-stages HCC. Surgical resection and radiofrequency destruction represent potentially curative options in highly selected patients. Arterial embolizations, chemo- or radio-embolizations, allow local tumor control but are not curative. These techniques could be performed before surgical resection or LT, to downstage the tumor and/or to control tumor progression while waiting for a graft. Finally, sorafenib is the only systemic treatment which has shown a survival benefit in advanced HCC. The benefit of combination of sorafenib and surgical treatments remains undetermined. The challenge in the management of HCC in cirrhotic patients is to integrate both individual (age, comorbidities, cirrhosis stage, tumor stage, specific contraindications to LT, etc.) and collective variables (expected waiting time before LT) to determine the best therapeutic option for each patient. In this process, multidisciplinarity is a key for success.

The treatment of hepatocellular carcinoma (HCC) in cirrhotic patients is challenging: the incidence is increasing, the cirrhosis dramatically limits the tolerance to treatment possibilities, there are many therapeutic modalities but resources are limited, namely in the context of organ shortage for transplantation. Liver transplantation (LT) is the optimal treatment as it combines the largest tumor resection possible and the correction of the underlying liver disease. Due to organ shortage however, LT is reserved for early-stages HCC. Surgical resection and radiofrequency destruction represent potentially curative options in highly selected patients. Arterial embolizations, chemo- or radio-embolizations, allow local tumor control but are not curative. These techniques could be performed before surgical resection or LT, to downstage the tumor and/or to control tumor progression while waiting for a graft. Finally, sorafenib is the only systemic treatment which has shown a survival benefit in advanced HCC. The benefit of combination of sorafenib and surgical treatments remains undetermined. The challenge in the management of HCC in cirrhotic patients is to integrate both individual (age, comorbidities, cirrhosis stage, tumor stage, specific contraindications to LT, etc.) and collective variables (expected waiting time before LT) to determine the best therapeutic option for each patient. In this process, multidisciplinarity is a key for success.

The treatment of hepatocellular carcinoma (HCC) in cirrhotic patients is challenging: the incidence is increasing, the cirrhosis dramatically limits the tolerance to treatment possibilities, there are many therapeutic modalities but resources are limited, namely in the context of organ shortage for transplantation. Liver transplantation (LT) is the optimal treatment as it combines the largest tumor resection possible and the correction of the underlying liver disease. Due to organ shortage however, LT is reserved for early-stages HCC. Surgical resection and radiofrequency destruction represent potentially curative options in highly selected patients. Arterial embolizations, chemo- or radio-embolizations, allow local tumor control but are not curative. These techniques could be performed before surgical resection or LT, to downstage the tumor and/or to control tumor progression while waiting for a graft. Finally, sorafenib is the only systemic treatment which has shown a survival benefit in advanced HCC. The benefit of combination of sorafenib and surgical treatments remains undetermined. The challenge in the management of HCC in cirrhotic patients is to integrate both individual (age, comorbidities, cirrhosis stage, tumor stage, specific contraindications to LT, etc.) and collective variables (expected waiting time before LT) to determine the best therapeutic option for each patient. In this process, multidisciplinarity is a key for success.