Higher Severe Morbidity Research Articles

L’accouchement des femmes enceintes de jumeaux : les enseignements de l’étude nationale observationnelle prospective comparative JUMODA

ObjectivesTo summerize the results of the JUMODA study (JUmeaux MODe d’Accouchement) on the planned mode of delivery of twin pregnancy and the management of second twin delivery. MethodsJUMODA was a national observational prospective comparative study that took place between february 2014 and march 2015 in 176 french maternity units performing more than 1500 deliveries per year. Its main objectives were the comparison of neonatal and maternal morbidity according to the planned mode of delivery and the determination of the managements of second twin delivery associated with the best neonatal outcomes. To control for potential confounding factors and indication biases, statistical analyses comprized multivariate logistic regressions and matching on propensity scores. ResultsThe JUMODA study recruited 8823 women with twin delivery at or beyond 22 weeks of gestation. For twin pregnancies with a cephalic first twin at 32 weeks of gestation and beyond, severe neonatal morbidity was higher in the planned cesarean (150/2908 (5.2 %) than in the planned vaginal delivery group (199/8922 (2.2 %), aOR 1.56, 95 % CI 1.19-2.04). Increased neonatal morbidity in the planned cesarean delivery group was explained by higher severe morbidity in neonates born preterm (aOR 1.64, 95 % CI 1.13-2.39, for deliveries between 32+0 and 34+6 weeks of gestation, aOR 2.04, 95 % CI 1.22-3.41, for deliveries between 35+0 SA and 36+6 weeks of gestation) but not in neonates born at term (aOR 1.19, 95 % CI 0.58-2.44). In comparison with planned cesarean delivery, planned vaginal delivery was not associated with increased severe neonatal morbidity in case of breech presenting first twin after 32 weeks of gestation or with decreased survival witout severe neonatal morbidity in case of delivery before 32 weeks of gestation whatever the first twin presentation. In comparison with planned vaginal delivery, planned cesarean delivery was associated with increased severe maternal morbidity only in women aged 35 and higher. Delivery of non cephalic second twin was associated with similar severe neonatal morbidity rate than delivery of cephalic second twin. Finally, in case of cephalic second twin, internal version followed by total breech extraction was associated with less cesarean for the second twin but with higher severe neonatal morbidity in case of preterm birth in comparison with pushing efforts, ocytocin perfusion and artificial rupture of membranes. ConclusionsPlanned vaginal delivery is the planned mode of delivery to encourage for the majority of pregnant women with twins, whatever first twin presentation and gestational age at delivery. No management of cephalic second twin appears better than an other, its choice will rest on obstetrician preferences.

Stratification of Major Hepatectomies According to Their Outcome: Analysis of 2212 Consecutive Open Resections in Patients Without Cirrhosis.

To stratify major hepatectomies (MajHs) according to their outcomes. MajHs are associated with non-negligible operative risks, but they include a wide range of procedures. Detailed depiction of the outcomes of different MajHs is the basis for a new classification of liver resections. We retrospectively considered patients that underwent hepatectomy in 17 high-volume centers. Patients with an associated digestive/biliary resection were excluded. We analyzed open MajHs in non-cirrhotic patients. MajHs were classified according to the Brisbane nomenclature. Right hepatectomies (RHs) were reference standards. Outcomes were adjusted for potential confounders, including indication, liver function, preoperative portal vein embolization, and enrolling center. We analyzed a series of 2212 patients. In comparison with RH, left hepatectomy had lower mortality [0.6% vs 2.2%, odds ratio (OR) = 0.25], severe morbidity (11.7% vs 14.4%, OR = 0.62), and liver failure rates (2.1% vs 11.6%, OR = 0.16). Left hepatectomy+Sg1 and mesohepatectomy+/-Sg1 had outcomes similar to RH, except for higher bile leak rate (31.3% and 13.5% vs 6.7%, OR = 4.36 and OR = 2.29). RH + Sg1 had slightly worse outcomes than RH. Right and left trisectionectomies had higher mortality (5.0% and 7.3% vs 2.2%, OR = 2.07 and OR = 2.71) and liver failure rates than RH (19.0% and 22.0% vs 11.6%, OR = 2.03 and OR = 2.21). Left trisectionectomy had even higher severe morbidity (25.6% vs 14.4%, OR = 2.07) and bile leak rates (14.6% vs 6.7%, OR = 2.31). The term "major hepatectomy" includes resections having heterogeneous outcome. Different MajHs can be stratified according to their mortality, severe morbidity, liver failure, and bile leak rates.

1647P - First-line treatment of desmoid tumor: Systemic therapy versus upfront surgery

Background: Desmoid tumor (DT) is a rare and locally invasive proliferative disease. The standard first-line treatment used to be radical surgical resection. However, during recent years it has been debated whether to offer an aggressive and morbidity treatment to a potentially indolent tumor. Desmoid tumor has uncertain behavior, some are aggressive cases, others indolent and there are some reports of spontaneous involution. Nowadays, the guidelines suggest to watch and wait before offering an aggressive treatment, and avoiding the surgical treatment. But in our experience patients had less morbidity and disease progression with a surgical approach. Methods: Patients with histological diagnosis of DT and treated at INCA between January 1998 and December 2015 were identified and their medical records were analyzed. Results: Of 191 patients evaluated, there were 137 females (71.2%). The median age at diagnosis was 34 years (range:17.79-76.96y). Tumor locations were: thoracoabdominal wall (n = 100, 52.3%), extremities (n = 53,27.7%), abdominal cavity (n = 26; 13.6%), and head and neck (n = 12, 6.2%). Tumor sizes were documented in 152 cases (79.5%) and ranged from 1 cm to 37 cm (median, 10 cm). Twenty-seven pts (14.1%) received systemic therapy (ST) (n = 5 vinblastine and methotrexate; n = 22 tamoxifen) and 164 pts (85.8%) were submitted to surgery (4pts received adjuvant tamoxifen) as first-line treatment. There was no difference between gender (p = 0.86), tumor location (p = 0.30), or tumor size (p = 0.53) when choosing first-line treatment. The odds of severe morbidity were 2.13 higher with ST than with upfront surgery. Four pts were submitted to surgery after systemic first-line treatment. After a median follow-up of 71 months, there was significantly more disease progression in the ST group (17pts – 62.9%) than in the surgery group (55 pts – 33.5%) (p = 0.005), and they received more subsequent treatment (p = 0,01). There were 2 deaths in the ST group and 9 deaths in the surgery group, with 10-year survival of 93.2% and 92%, respectively. Conclusions: DT is an indolent disease but has the propensity for locally invasive growth and recurrence. Although ST is a less aggressive treatment, it was associated with higher severe morbidity, more disease progression, and more subsequent treatment in this trial. Legal entity responsible for the study: INCA. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.