BACKGROUND:Pancreatic resection (PR) may require portal/superior mesenteric vein resection (VR). Outcomes of minimally invasive PR (MIPR) with VR are poorly studied. METHODS:Multicentric retrospective cohort of MI pancreatoduodenectomy (MIPD) and left pancreatectomy (MILP) with or without VR between 2010 and 2021. Propensity score matching analysis stratified on age, sex, BMI, pancreas texture, tumor type, ASA score, conversion and surgical approach was performed. RESULTS:After matching, 234 MIPD were included, 78 (33.3%) with and 156 (66.7%) without VR. VR had greater blood loss (400 vs 300 mL; p = 0.033) and operative time (471 vs 430 min; p = 0.012). VR had 10.3% mortality compared to 4.5% (p = 0.097), similar severe morbidity (30.8% vs 37.8%: p = 0.313) and R0 resection rate (84.9% vs 90.8%: p = 0.252). After matching, 275 MILP, 25 (9%) with and 250 (91%) without VR were compared. VR had greater blood loss (350 vs 150mL; p = 0.019) and operative time (300 vs 240 min; p = 0.005). VR had 8% mortality versus 2% (p = 0.126), 19.2% severe morbidity versus 8% (p = 0.274) and lower R0 resection rate (58.3% vs 94.9%; p <0.001). CONCLUSION:MIPR with VR has non-significant increased postoperative mortality, lower R0 resection rate and therefore cannot be considered as a standard of care.

Objective To describe surgical indications, procedures and outcomes in patients operated for Zollinger-Ellison syndrome (ZES) in multiple endocrine neoplasia type 1 (MEN1) using a large nationwide cohort. Background Management of ZES in MEN1 remains controversial. Methods All patients with ZES diagnosed through the MEN1 AFCE/GTE network from 1985 to 2015.Results Among 233 ZES patients, 66 (28%) were operated for ZES-related gastrinomas. Thirty-three (51%) procedures aimed to remove gastrinomas and associated pancreatic neuroendocrine tumors (pNET(s)) with appropriate resection. Thirty-two procedures (49%) aimed to remove gastrinomas alone (ZES group). Survival was decreased in patients metastatic at ZES diagnosis (p < 0.001). Fifteen-year survival among non-metastatic patients was not significantly better in operated patients (82% vs. 70%, p = 0.2). Perioperative mortality was nil. Metastatic lymph nodes were found in 30/42 lymphadenectomies (71%). The choice between pancreaticoduodenectomy versus duodenal focused surgery in the ZES group was associated with pre-operative detection of adenopathies (p > 0.001), leading to more frequent lymphadenectomies (p < 0.01). Previous pancreatic surgeries (30%) may have influenced the choice of ZES procedures. Gastrin levels were more frequently normalized when the duodenum and the head of pancreas were removed versus more localized duodenal surgeries (p < 0.01). Conclusion The high rate of invaded nodes in lymphadenectomies in MEN1 patients operated for ZES, the absence of operative mortality, and the decreased survival in metastatic patients are indirect arguments for surgery. Pancreaticoduodenectomy may be indicated in young and fit individuals to better control hypergastrinemia and to prevent metastatic progression in the ZES group. Gastrinoma removal is justified when associated with large pNETs.

BACKGROUND:Alveolar echinococcosis (AE) is a rare benign but potentially life-threatening condition. Albeit benign, recurrence after surgical resection remains frequent. Systematic perioperative benzimidazoles (BZM) treatment along with complete and large resection margin have been advocated to prevent recurrence, although data on long-term outcomes are lacking. METHODS:Consecutive patients who underwent hepatectomy for AE between 2005 and 2023 were included. Perioperative management and long-term outcomes were analyzed. RESULTS:Over the study period, 76 patients underwent hepatectomy for AE, of which 71 (93 %) received preoperative antiparasitic treatment. R0 rate was 58 % and R1 resection rate was 41 %, including 21 planned R1 resections. Severe morbidity occurred in 7 patients (9 %) including one postoperative death. Overall, 70 patients (92 %) received postoperative treatment for a median duration of 24 months (range, 10-108). After a median follow-up of 48 months (range, 10-226), 2 patients developed recurrence. No recurrence was observed in patients who underwent planned R1 resections. Overall survival at 5 and 10 years were 99 % and 86 % respectively. CONCLUSION:Hepatectomycombined with perioperative parasitostatic treatment allowed prolonged overall survival similar to the general population. R1 resection does not seem to influence survival.

AIM:Anastomotic leak (AL) is a major problem in colorectal surgery, and its prevention is crucial for patient safety. The scientific literature shows that optimal anastomotic perfusion is essential for anastomotic healing. However, in cases of left colon or rectal cancer requiring high vessel ligation for oncological reasons, anastomotic blood supply relies mainly on the pericolic arterial arcades. Consequently, assessing anastomotic perfusion using intraoperative fluorescence angiography with indocyanine green might be relevant to reduce the risk of AL. Although evidence of its positive impact on the risk of AL is growing in the literature, most studies are descriptive prospective cohorts or retrospective comparative series with controversial findings. Furthermore, no other studies specifically address left-sided colon or high rectal tumours. FLUOCOL-1 is a large multicentre randomized controlled trial (RCT) that aims to demonstrate that assessing anastomotic perfusion using intraoperative fluorescence angiography with indocyanine green will reduce ALs in left-sided or high anterior resections with intraperitoneal anastomosis METHOD: FLUOCOL-1 is a French multicentre, single-blind, randomized, two-arm, phase III superiority clinical trial. Patients will be randomized in a 1:1 ratio to either the intervention group (FLUO+) or the control group (FLUO-). A total of 1010 patients will be randomized. The primary endpoint is the occurrence of an AL within 90 days postsurgery. AL is defined as any anastomotic dehiscence with leakage into the pelvic cavity diagnosed by imaging or surgical exploration, or any isolated pelvic organ-space infection with no evidence of fistula, as defined by the International Study Group of Rectal Cancer. DISCUSSION:Prevention of AL is one of the most important questions to be addressed in colorectal surgery. The FLUOCOL-1 multicentre RCT described herein aims to demonstrate that assessment of anastomotic perfusion using intraoperative fluorescence angiography with indocyanine green will reduce ALs in certain resections with intraperitoneal anastomosis.

BACKGROUND:Intraoperative autotransfusion remains underutilized in high-risk haemorrhagic oncological procedures, particularly in liver transplantation for hepatocellular carcinoma. This is because of the theoretical risk of tumour cell reinfusion and dissemination, potentially leading to reduced recurrence-free survival. The aim of this study was to evaluate the impact of intraoperative autotransfusion on recurrence-free survival during liver transplantation for hepatocellular carcinoma. METHODS:This was a retrospective study of patients receiving liver transplantation for hepatocellular carcinoma with or without intraoperative autotransfusion between 1 January 2011 and 1 January 2020 at five French hospitals, of which one used autotransfusion and four did not. Propensity score matching was used to match the cohorts with and without autotransfusion. The primary endpoint was 5-year recurrence-free survival. RESULTS:Some 113 patients in the study cohort (autotransfusion) were compared with 441 patients in the control cohort. The median volume of autotransfused blood was 1500 ml. Median follow-up was 84.6 months. There was no significant difference in 5-year recurrence-free survival between the cohorts (69.7% in control cohort versus 66.3% in study cohort; P = 0.241). After matching patients based on oncological criteria, the difference remained non-significant, with a 5-year recurrence-free survival rate of 67.1% in the study cohort and 77.6% in the control cohort (P = 0.174). CONCLUSION:The use of autotransfusion during liver transplantation for hepatocellular carcinoma was not associated with recurrence-free survival.

The use of multiagent FOLFIRINOX chemotherapy for pancreatic adenocarcinoma in a neoadjuvant setting has been associated with an increased rate of complete pathological response (CPR) after surgery. This study investigated the long-term outcomes of patients with CPR in a multicenter setting to identify prognostic factors for overall survival (OS) and recurrence-free survival (RFS). This retrospective cohort study examined biopsy-proven pancreatic adenocarcinomas with CPR after neoadjuvant chemotherapy or chemoradiotherapy and surgery, between January 2006 and December 2023 across 22 French and 2 Belgian centers. Cox analyses were used to identify prognostic factors of OS and RFS. There were 101 patients with CPR after chemotherapy (n = 58, 57.4

Background Distal pancreatectomy is frequently indicated for left-sided pancreatic neuroendocrine tumour (NET). When combined lymphadenectomy is warranted, distal pancreatectomy with splenectomy (DPS) is generally advocated to optimize lymph node dissection. The spleen-preserving distal pancreatectomy (SPDP) may represent an alternative approach. This study aimed to evaluate postoperative and oncological results of distal pancreatectomy with and without splenectomy for pancreatic NET. Methods This multicentre retrospective study included all distal pancreatectomy for pancreatic NET performed between 2014 and 2018. Patients with functional NET or multiple endocrine neoplasia type 1 were excluded. Indications and results were compared between DPS, distal pancreatectomy according to Kimura (K-SPDP) and distal pancreatectomy according to Warshaw (W-SPDP), before and after propensity score matching (PSM). Results Among 251 patients included (108 DPS (43%), 73 K-SPDP (29%), and 70 W-SPDP (28%)), there was no difference in terms of patients’ characteristics, surgical approach, and conversion. Tumour size (P = 0.005), grade (P < 0.001) and the number of nodes analysed (P < 0.001) were significantly lower in patients undergoing K-SPDP as compared to W-SPDP or DPS. Apart from a difference in readmission rate (P = 0.002), there was no difference in terms of mortality rate or severe morbidity rate between the three techniques. After PSM comparing DPS (n = 70) and W-SPDP (n = 70), there was no difference in morbidity and mortality rates. R0 resection rate (91% versus 97%; P = 0.165), the number of nodes analysed (8 versus 7; P = 0.495), and median overall survival (P = 0.493) were not different. Conclusion In cases of distal pancreatectomy for NET, splenectomy did not seem to improve lymph node dissection or survival. When lymph node dissection associated with distal pancreatectomy is justified, the benefit of splenectomy appears questionable.

The planification of radiation therapy (RT) for pancreatic cancer (PC) requires a dosimetric computed tomography (CT) scan to define the gross tumor volume (GTV). The main objective of this study was to compare the inter-observer variability in RT planning between the arterial and the venous phases following intravenous contrast. PANCRINJ was a prospective monocentric study that included twenty patients with non-metastatic PC. Patients underwent a pre-therapeutic CT scan at the arterial and venous phases. The delineation of the GTV was performed by one radiologist (gold standard) and two senior radiation oncologists (operators). The primary objective was to compare the Jaccard conformity index (JCI) for the GTVs computed between the GS (gold standard) and the operators between the arterial and the venous phases with a Wilcoxon signed rank test for paired samples. The secondary endpoints were the geographical miss index (GMI), the kappa index, the intra-operator variability, and the dose-volume histograms between the arterial and venous phases. The median JCI for the arterial and venous phases were 0.50 (range, 0.17–0.64) and 0.41 (range, 0.23–0.61) (p = 0.10) respectively. The median GS-GTV was statistically significantly smaller compared to the operators at the arterial (p < 0.0001) and venous phases (p < 0.001), respectively. The GMI were low with few tumors missed for all patients with a median GMI of 0.07 (range, 0-0.79) and 0.05 (range, 0-0.39) at the arterial and venous phases, respectively (p = 0.15). There was a moderate agreement between the radiation oncologists with a median kappa index of 0.52 (range 0.38–0.57) on the arterial phase, and 0.52 (range 0.36–0.57) on the venous phase (p = 0.08). The intra-observer variability for GTV delineation was lower at the venous phase than at the arterial phase for the two operators. There was no significant difference between the arterial and the venous phases regarding the dose-volume histogram for the operators. Our results showed inter- and intra-observer variability in delineating GTV for PC without significant differences between the arterial and the venous phases. The use of both phases should be encouraged. Our findings suggest the need to provide training for radiation oncologists in pancreatic imaging and to collaborate within a multidisciplinary team.

Background Despite the increasing eff i cacy of chemotherapy (C), the 5 -year survival rate for patients with unresectable colorectal liver metastases (CLM) remains around 10%. Liver transplantation (LT) might offer a curative approach for patients with liver-only disease, yet its superior eff i cacy compared to C alone remains to be demonstrated. Methods The TransMet randomised multicentre clinical trial (NCT02597348) compares the curative potential of C followed by LT versus C alone in patients with unresectable CLM despite stable or responding disease on C. Patient eligibility criteria proposed by local tumour boards had to be validated by an independent committee via monthly videoconferences. Outcomes reported here are from a non-speci fi ed interim analysis. These include the eligibility of patients to be transplanted for non resectable colorectal liver metastases, as well as the feasibility and the safety of liver transplantation in this indication. Findings From February 2016 to July 2021, 94 (60%) of 157 patients from 20 centres in 3 countries submitted to the validation committee, were randomised. Reasons for ineligibility were mainly tumour progression in 50 (32%) or potential resectability in 13 (8%). The median delay to LT after randomisation was 51 (IQR 30 - 65) days. Nine of 47 patients (19%, 95% CI: 9 - 33) allocated to the LT arm failed to undergo transplantation because of intercurrent disease progression. Three of the 38 transplanted patients (8%) were re-transplanted, one of whom (3%) died post-operatively from multi-organ failure. Interpretation The selection process of potential candidates for curative intent LT for unresectable CLM in the TransMet trial highlighted the critical role of an independent multidisciplinary validation committee. After stringent selection, the feasibility of LT was 81%, as 19% had disease progression while on the waiting list. These patients should be given high priority for organ allocation to avoid dropout from the transplant strategy.

BACKGROUND:Appropriate risk stratification for the difficulty of liver transplantation (LT) is essential to guide the selection and acceptance of grafts and avoid morbidity and mortality. METHODS:Based on 987 LTs collected from 5 centers, perioperative outcomes were analyzed across the 3 difficulty levels. Each LT was retrospectively scored from 0 to 10. Scores of 0-2, 3-5 and 6-10 were then translated into respective difficulty levels: low, moderate and high. Complications were reported according to the comprehensive complication index (CCI). RESULTS:The difficulty level of LT in 524 (53%), 323 (32%), and 140 (14%) patients was classified as low, moderate and high, respectively. The values of major intraoperative outcomes, such as cold ischemia time (p = 0.04) and operative time (p < 0.0001) increased gradually with statistically significant values among difficulty levels. There was a corresponding increase in CCI (p = 0.04), severe complication rates (p = 0.05) and length of ICU (p = 0.01) and hospital (p = 0.004) stays across the different difficulty levels. CONCLUSION:The LT difficulty classification has been validated.

After total thyroidectomy (TT), postoperative hypoparathyroidism (PH) is the most frequent complication. Yet, management strategies for PH remain disputed. The aim of this study was to evaluate outcomes of a reactive supplementation in case of symptomatic PH. Additionally, risk factors for symptomatic PH and readmission due to PH were analyzed. All consecutive patients who underwent TT or completion from 2017 to 2022 were considered for inclusion. During this period, a reactive to symptom vitamin-calcium supplementation was used. The primary outcome was the occurrence of severe PH after discharge resulting in readmission. Overall, 307 patients were included, of which 98 patients (31.9

Background: Data on clinically relevant post-pancreatectomy hemorrhage (CR-PPH) are derived from series mostly focused on pancreatoduodenectomy, and data after distal pancreatectomy (DP) are scarce. Methods: All non -extended DP performed from 2014 to 2018 were included. CR-PPH encompassed grade B and C PPH. Risk factors, management, and outcomes of CR-PPH were evaluated. Results: Overall, 1188 patients were included, of which 561 (47.2 %) were operated on minimally invasively. Spleen -preserving DP was performed in 574 patients (48.4 %). Ninety -day mortality, severe morbidity and CR-POPF rates were 1.1 % (n = 13), 17.4 % (n = 196) and 15.5 % (n = 115), respectively. After a median interval of 8 days (range, 0-37), 65 patients (5.5 %) developed CR-PPH, including 28 grade B and 37 grade C. Reintervention was required in 57 patients (87.7 %). CR-PPH was associated with a significant increase of 90 -day mortality, morbidity and hospital stay (p < 0.001). Upon multivariable analysis, prolonged operative time and co -existing POPF were independently associated with CR-PPH (p < 0.005) while a chronic use of antithrombotic agent trended towards an increase of CR-PPH (p = 0.081). As compared to CR-POPF, the failure -to -rescue rate in patients who developed CR-PPH was significantly higher (13.8 % vs. 1.3 %, p < 0.001). Conclusion: CR-PPH after DP remains rare but significantly associated with an increased risk of 90 -day mortality and failure -to -rescue.

Purpose: The French controlled donation after circulatory death (cDCD) liver transplant (LT) program with normothermic regional perfusion (NRP) has achieved benchmark outcomes using strict selection criteria. To reduce graft discard rates, selection criteria were extended in September 2021 with mandatory use of hypothermic oxygenated perfusion (HOPE) after NRP. Method: All consecutive cDCD LT performed in 4 centers since the extension of selection criteria were included and followed up for 3 months. HOPE was mandatory in liver grafts previously discarded for transaminase levels ranging from 4N-8N during NRP and/or 20%-30% macrosteatosis. Outcomes after NRP+HOPE were compared to NRP alone. Results: Fifty-nine cDCD grafts were transplanted during the study period of which 13(22%) underwent NRP+HOPE due to high NRP transaminase levels (85%) or liver steatosis (15%). Donor characteristics and warm ischemia times were comparable between both groups except for significantly higher peak transaminases during NRP in the NRP+HOPE group. (Table 1, Figure 1). The median HOPE duration was 113 min resulting in a significantly longer ex-vivo preservation (412 vs 347 min, p=0.130) compared to the NRP group. The NRP+HOPE group displayed a lower early allograft dysfunction rate (7.7 vs 21.7%, p=0.251) with comparable L-Graft7 risk scores (-3.21 vs -3.89, p=0.182). Arterial and biliary complications were similar between both groups without occurrence of primary nonfunction or re-LT after NRP+HOPE. Conclusion: HOPE after NRP resulted in transplantation of >20% additional grafts otherwise discarded with the strict French selection criteria. Additional HOPE significantly prolonged ex-vivo preservation and achieved early outcomes observed in highly selected NRP cDCD grafts.Tabled 1Table 1: Donor and graft characteristics and early post-transplant outcomesNRP n= 46NRP+HOPE n= 13PDonor age, years56 (42-62)53 (51-58)nsMacrosteatosis > 20%, n(%)0 (0)2 (15)p=0.007TDWI, min30 (27-40)36 (30-54)nsFDWI, min22 (18-25)22 (19-25)nsAWI, min18 (15-22)18 (17-20)nsNRP duration, min195 (160-229)205 (176-230)nsStatic cold storage time, min347 (316-408)325 (284-356)nsBiliary complications, n (%)7 (15.2)2 (15.4)ns- NAS, n(%)1 (2.2)0 (0)nsRe-transplantation, n (%)1(2.2)0 (0)ns- Arterial thrombosis, n1(2.2)0 (0)ns3 months graft loss, n (%)1(2.2)0 (0)ns3 months mortality, n (%)1(2.2)0 (0)NsTDWI: total donor warm ischemia; FDWI: functional donor warm ischemia; AWI: asystolic warm ischemia; NRP: normothermic regional perfusion; NAS: non anastomotic stenosis Open table in a new tab TDWI: total donor warm ischemia; FDWI: functional donor warm ischemia; AWI: asystolic warm ischemia; NRP: normothermic regional perfusion; NAS: non anastomotic stenosis

Purpose: Alveolar echinococcosis (AE) is a rare benign but potentially life-threatening condition. Recurrence after surgical resection remains rather frequent. Systematic perioperative benzimidazoles (BZM) treatment, acting as parasitostatics in AE, has been advocated to prevent recurrence. Nevertheless, data on long-term outcomes are lacking. Methods: Consecutive patients who underwent hepatectomy for AE between 2001 and 2021 were included. Perioperative management and long-term outcomes were analyzed. Results: Over the study period, 70 patients underwent hepatectomy for AE, of which 65 (93%) received preoperative BZM. Main reason for not receiving preoperative BZM was an initial misdiagnosis (80%). Preoperative portal vein embolization was undertaken in 7 patients (10%) while major hepatectomy was performed in 47 patients (67%). Combined vascular and/or biliary reconstruction was performed in 22 patients (31%) and extrahepatic resection was required in 16 patients (23%) including 2 patients with peritoneal disease. Severe morbidity occurred in 7 patients (9%) including one postoperative death. Complete R0 margin status was achieved in 41 patients (59%) while one (1%) underwent R2 debulking hepatectomy. Overall, 64 patients (91%) received postoperative BZM for a median duration of 24 months (range, 12-108). After a median follow-up of 48 months (range, 12-266), 2 patients developed recurrence. One experienced liver recurrence 197 months after surgery and one recurred in the liver and lung 20 months after surgery. Overall survival at 5 and 10 years were 100% and 86% respectively. Conclusion: Hepatectomy combined with perioperative BZM allowed prolonged overall survival in AE.

Background: Anastomotic leakage presentation after Ivor Lewis esophagectomy may vary on imaging. Such variations may influence anastomotic leakage management and outcomes.Methods: All consecutive patients who underwent Ivor Lewis esophagectomy for cancer between 2012 and 2019 in 2 referral centers were included. Anatomical patterns of anastomotic leakage were defined on imaging as follows: eso-mediastinal anastomotic leakage was a leak contained in the posterior mediastinum, eso-pleural anastomotic leakage was a leak involving the pleural cavity, and eso-bronchial anastomotic leakage was a leak communicating with the tracheobronchial tract. According to the Esophageal Complications Consensus Group definition, management and 90-day mortality were evaluated according to these patterns.Results: Among 731 patients, 111 (15%) developed anastomotic leakage consisting of eso-mediastinal anastomotic leakage (n = 87, 79%), eso-pleural anastomotic leakage (n = 16, 14%) and eso-bronchial anastomotic leakage (n = 8, 7%). There was no difference among these groups regarding preoperative characteristics or time to anastomotic leakage diagnosis. There was a significant difference in initial management according to anastomotic leakage anatomic patterns (P = .001). More than half of patients who experienced eso-mediastinal anastomotic leakage (n = 46, 53%) were initially treated conservatively without requiring intervention (Esophageal Complications Consensus Group type I), whereas most patients with eso-pleural anastomotic leakage (n = 14, 87.5%) and all with eso-bronchial anastomotic leakage (n = 8, 100%) initially required interventional or surgical treatment (Esophageal Complications Consensus Group type II-III). Anastomotic leakage anatomic patterns had a statistically significant impact on 90-day mortality, intensive care unit stay, and total hospital stay (P < .001).Conclusion: Anastomotic leakage anatomic patterns after Ivor Lewis esophagectomy influence outcomes. Further studies are warranted to validate it in a prospective setting. Anastomotic leakage anatomic patterns may help in guiding anastomotic leakage management.& COPY; 2023 Elsevier Inc. All rights reserved.

CD226 has been reported to participate in the rescue of CD8 + T cell dysfunction. In this study, we aimed to assess the prognostic value of CD226 in tumor-infiltrating lymphocytes (TILs) derived from colorectal cancer (CRC) liver metastases treated with chemotherapy and radical surgery. TILs from 43 metastases were isolated and analyzed ex vivo using flow cytometry. CD155 and CD3 levels in the tumor microenvironment were assessed by immunohistochemistry. Exploration and validation of biological processes highlighted in this study were performed by bioinformatics analysis of bulk RNA-seq results for 28 CRC liver metastases pretreated with chemotherapy as well as public gene expression datasets. CD226 expression contributes to the definition of the immune context in CRC liver metastases and primary tumors. CD226 on CD8 + T cells was not specifically coexpressed with other immune checkpoints, such as PD1, TIGIT, and TIM3, in liver metastases. Multivariate Cox regression analysis revealed CD226 expression on CD8 + T cells to be an independent prognostic factor ( p = 0.003), along with CD3 density at invasion margins ( p = 0.003) and TIGIT expression on CD4 + T cells ( p = 0.019). CD155 was not associated with the prognostic value of CD226. Gene expression analysis in a validation dataset confirmed the prognostic value of CD226 in CRC liver metastases but not in primary tumors. Downregulation of CD226 on CD8 + TILs in the liver microenvironment was restored by IL15 treatment. Overall, CD226 expression on liver metastasis-infiltrating CD8 + T cells selectively contributes to immune surveillance of CRC liver metastases and has prognostic value for patients undergoing radical surgery.

The purpose of this study was to identify the preoperative CT features that are associated with inadvertent enterotomy (IE) during adhesive small bowel obstruction (ASBO) surgery. From January 2015 to December 2019, all patients with ASBO who underwent an abdominal CT were reviewed. Abdominal CT were retrospectively reviewed by two radiologists with a consensus read in case of disagreement. IE during ASBO surgery was retrospectively recorded. Univariate and multivariate analyses of CT features associated with IE were performed and a simple CT score was built to stratify the risk of IE. This score was validated in an independent retrospective cohort. Abdominal CT of the validation cohort was reviewed by a third independent reader. Among the 368 patients with ASBO during the study period, 169 were surgically treated, including 129 ASBO for single adhesive band and 40 for matted adhesions. Among these, there were 47 IE. By multivariate analysis, angulation of the transitional zone (OR = 4.19, 95% CI [1.10–18.09]), diffuse intestinal adhesions (OR = 4.87, 95% CI [1.37–19.76]), a fat notch sign (OR = 0.32, 95% CI [0.12–0.85]), and mesenteric haziness (OR = 0.13, 95% CI [0.03–0.48]) were independently associated with inadvertent enterotomy occurrence. The simple CT score built to stratify risk of IE displayed an AUC of 0.85 (95% CI [0.80–0.90]) in the study sample and 0.88 (95% CI [0.80–0.96]) in the validation cohort. A simple preoperative CT score is able to inform the surgeon about a high risk of IE and therefore influence the surgical procedure. • In this retrospective study of 169 patients undergoing abdominal surgery for adhesive small bowel obstruction, 47 (28%) inadvertent enterotomy occurred. • A simple preoperative CT score enables accurate stratification of inadvertent enterotomy risk (area under the curve 0.85). • By multivariable analysis, diffuse intestinal adhesions and angulation of the transitional zone were predictive of inadvertent enterotomy occurrence.