Anne-Sophie Schneck

Regular coffee but not espresso drinking is protective against fibrosis in a cohort mainly composed of morbidly obese European women with NAFLD undergoing bariatric surgery

BACKGROUND & AIMS The aim of this study was to determine the influence of coffee and other caffeinated drinks on liver fibrosis of severely obese European patients. METHODS A specific questionnaire exploring various types of coffee (regular filtrated coffee and espresso), caffeinated drinks, and chocolate was filled in by 195 severely obese patients. All patients had liver biopsies that were analyzed according to the NASH Clinical Research Network Scoring System. Univariate and multivariate analyses of significant fibrosis were performed. RESULTS Caffeine came mainly from coffee-containing beverages (77.5%). Regular coffee and espresso were consumed in 30.8% and 50.2% of the patients, respectively. Regular coffee, espresso, and total caffeine consumption was similar between patients with and without NASH. While consumption of espresso, caffeinated soft drinks, and chocolate was similar among patients, with respect to the level of fibrosis, regular coffee consumption was lower in patients with significant fibrosis (F ≥2). According to logistic regression analysis, consumption of regular coffee was an independent protective factor for fibrosis (OR: 0.752 [0.578-0.980], p=0.035) in a model including level of AST (OR: 1.04 [1.004-1.076], p=0.029), presence of NASH (OR: 2.41 [1.007-5.782], p=0.048), presence of the metabolic syndrome (NS), and level of HOMA-IR (NS). Espresso, but not regular coffee consumption was higher in patients with lower HDL cholesterol level, higher triglyceride level, and the metabolic syndrome. CONCLUSIONS Consumption of regular coffee but not espresso is an independent protective factor for liver fibrosis in severely obese European patients.

Laparoscopic sleeve gastrectomy followed by duodenal switch in selected patients versus single-stage duodenal switch for superobesity: case–control study

BACKGROUND The prevalence of superobesity (body mass index [BMI] ≥50 kg/m(2)) has increased steadily during the past decade, and the most suitable surgical strategy for these patients is still controversial. Our objective was to test the hypothesis that in selected superobese patients, laparoscopic sleeve gastrectomy (SG) followed by laparoscopic duodenal switch (DS) might reduce the rate of postoperative complications and the need for the second step duodenal switch. The setting was a university hospital in France. METHODS A retrospective analysis was performed of a prospective database of 110 consecutive patients with a BMI of ≥50 kg/m(2) undergoing the staged approach and matched for age, gender, and BMI with 110 consecutive patients undergoing single-stage DS. The excess weight loss (EWL), co-morbidity improvement, and incidence of postoperative complications were compared between the 2 groups. RESULTS One patient died in the staged strategy group (mortality rate .9%). The postoperative complication rate was 8.2% in the staged strategy group (110 patients) and 15.5% in the single-stage DS group (110 patients; P = 1). Multivariate analysis showed that single-stage DS surgery is the only variable significantly associated with the occurrence of postoperative complications (odds ratio 2.36; 95% confidence interval 1.001-5.61). In the staged strategy group, at a mean follow-up of 36.4 ± 13 months, 39 patients (35.5%) required the second-stage procedure. The mean %EWL was 50.8% ± 17.5% for SG alone (35% failed to maintain 50% EWL after SG), 61.5% ± 19.3% for the staged strategy, 72.7% ± 14.1% for 2-step DS (3.3% failed to maintain 50% EWL after 2-step DS), and 73.3% ± 17.6% for single-stage DS (7.3% failed to maintain 50% EWL after single-stage DS). CONCLUSIONS At 3 years of follow-up, staged DS surgery avoided biliopancreatic diversion in 72.7% of the patients. Single-stage DS increases the risk of postoperative complications but not of anastomotic leak.

Gastric pouch resizing for Roux-en-Y gastric bypass failure in patients with a dilated pouch

BACKGROUND Insufficient weight loss or weight regain a few years after laparoscopic Roux-en-Y gastric bypass is becoming a serious problem given the large diffusion of this procedure. In the present study, we analyzed the feasibility and safety of pouch resizing for Roux-en-Y gastric bypass failure in a consecutive series of 20 patients at a university hospital. METHODS A prospectively maintained database was queried regarding patient demographics, the indication for revision morbidity, the percentage of excess weight loss, and the evolution of co-morbidities. RESULTS A total of 20 patients, 18 women and 2 men, with a mean age of 44 years and mean body mass index of 45.8 kg/m(2), underwent pouch resizing. No patients died; 6 patients (30%) developed complications, including acute abdomen due to volvulus of the small bowel in 1, intra-abdominal abscess in 3, and pulmonary embolus in 2. At a mean follow-up of 20 months, the percentage of excess weight loss was an average of 69.1% and persistent co-morbidities had improved or resolved. CONCLUSION Pouch resizing has been shown to be a valuable option in the short term for weight loss failure or regain in patients who have undergone laparoscopic Roux-en-Y gastric bypass and have a dilated gastric pouch. However, the long-term efficacy of this procedure needs to be determined.

Laparoscopic sleeve gastrectomy as a revisional procedure for failed gastric banding: lessons from 300 consecutive cases

BACKGROUND Laparoscopic adjustable gastric banding (LAGB) is a common bariatric procedure associated with a high rate of weight loss failure and/or complications in the long term. The objective of this study was to test the hypothesis that the conversion of failed LAGB into laparoscopic sleeve gastrectomy (LSG) is not associated with an increased risk of postoperative complications and leads to weight loss results that are comparable to those obtained with a primary LSG. METHODS We retrospectively analyzed the results of a prospective series of 1360 LSG regarding patient demographics, the indication for revision morbidity, the percentage of excess weight loss, and the rate of postoperative complications. RESULTS The primary LSG group contained 1060 patients and the LAGB to LSG group contained 300 patients. The rate of postoperative complications was 4.5% in the primary LSG group and 2% in the LAGB to LSG group. Two patients died in the LSG group (1 pulmonary embolus, 1 myocardial infarction). There was no significant difference with respect to the rate of leak, which was 1% in the LAGB to LSG group and 1.6% in the primary LSG group. There was a greater weight loss after primary LSG, mean % excess weight loss of 75.9%±21.4 at a mean interval of 29±19.8 months, versus 62.6%±22.2 at a mean interval of 35±24 months after LAGB to LSG (P = .008). There were 72.1% and 59.2% of patients available for follow-up after primary LSG at 24 and 60 months respectively, versus 69.3% and 55.4% after LAGB to LSG. CONCLUSION This study indicates that the risk of leak after LSG was not increased after conversion failed LAGB into LSG when performed as a 2-step procedure.

Reduction in early mortality outcomes after bariatric surgery in France between 2007 and 2012: A nationwide study of 133,000 obese patients.

BACKGROUND Early postoperative mortality after bariatric surgery has been reported in large national studies before sleeve gastrectomy (SG) was introduced as a stand-alone procedure. The aim of this study was to investigate the 90-day postoperative mortality rates after bariatric surgery in France on a nationwide basis. METHODS All morbidly obese patients who underwent adjustable gastric banding (AGB), gastric bypass (GBP), or SG in France between 2007 and 2012 were included in this study. Multivariate analyses were conducted using the French National Health Service Database data to ascertain predictive factors for 90-day postoperative mortality. RESULTS Data from 133,804 patients were analyzed. SG was performed in 36.5% of cases, GBP in 31.2%, AGB in 32.3%, and revisional surgery in 5.1%. The postoperative mortality rate (POM) for the 3 procedures was 0.12%. The rate of POM remained stable for AGB (0.01%), and it decreased from 0.25 to 0.08% and from 0.36 to 0.11% for SG and GBP, respectively. POM was greater among male patients and was associated with age, type-2 diabetes, high blood pressure, body mass index, open surgery, and hospital procedural volume. CONCLUSION The rate of early mortality after bariatric surgery was low, and has decreased greatly during the past few years. AGB presents a mortality rate close to nil and SG has a risk of early mortality that is about half that of GBP.

Evolution of low-grade systemic inflammation, insulin resistance, anthropometrics, resting energy expenditure and metabolic syndrome after bariatric surgery: a comparative study between gastric bypass and sleeve gastrectomy.

BACKGROUND Laparoscopic sleeve gastrectomy (LSG) for morbid obesity is gaining in popularity as it offers several advantages over laparoscopic Roux-en-Y gastric bypass (LRYGBP), but comparative data between these two procedures have rarely been reported. METHODS This case control study compared the incidence of low-grade systemic inflammation, insulin resistance, anthropometrics, resting energy expenditure and metabolic syndrome in 30 patients undergoing LRYGBP and 30 patients undergoing LSG, matched for age, sex, body mass index (BMI), and glycosylated hemoglobin (HbA1c). RESULTS At 1-year after surgery, the percent of excess weight loss was 67.8 ± 20.9 for LRYGBP and 61.6 ± 19.4 for LSG. Patients undergoing LRYGBP showed significantly lower plasma levels of C-reactive protein (3.3 ± 2.7 mg/dL vs. 5.3 ± 3.9 mg/dL; P < 0.05), waist circumference (97.4 ± 16.0 vs. 105.5 ± 14.7 cm; P < 0.05), total cholesterol (4.6 ± 1.0 vs. 5.7 ± 0.9 mmol/L; P < 0.01) and LDL cholesterol (2.6 ± 0.8 vs. 3.6 ± 0.8 mmol/L; P < 0.01). Insulin resistance (HOMA index 1.6 ± 1.0 after LRYGBP vs. 2.3 ± 2.4 after LSG), resting energy expenditure (1666.7 ± 320.5 after LRYGBP vs. 1600.4 ± 427.3 Kcal after LSG) and remission of metabolic syndrome (92.9% after LRYGBP vs. 80% after LSG) were not different between the two groups. CONCLUSION In this study, patients undergoing LRYGBP demonstrated significantly improved lipid profiles, decreased systemic low-grade inflammation compared with those undergoing LSG at 1-year follow-up.

Primary versus delayed repair for bile duct injuries sustained during cholecystectomy: results of a survey of the Association Francaise de Chirurgie

BACKGROUND Bile duct injuries (BDIs) sustained during a cholecystectomy still remain a major surgical problem, and it is still not clear whether the injury should be repaired immediately or a delayed repair is preferred. METHODS A retrospective national French survey was conducted to compare the results of immediate (at time of cholecystectomy), early (within 45 days after a cholecystectomy) and late (beyond 45 days after a cholecystectomy) surgical repair for BDI sustained during a cholecystectomy. RESULTS Forty-seven surgical centres provided 640 cases of bile duct injury sustained during a cholecystectomy of which 543 were analysed for the purpose of the present study. The timing of repair was immediate in 194 cases (35.7%), early in 216 cases (39.8%) and late in 133 cases (24.5%). The type of repair was a suture repair in 157 cases (81%), and a bilio-digestive reconstruction in 37 cases (19%) for immediate repair; a suture repair in 119 cases (55.1%) and a bilio-digestive anastomosis in 96 cases (44.9%) for the early repair; and a bilio-digestive reconstruction in 129 cases (97%) and a suture repair in 4 cases (3%) for late repair. A second procedure was required in 110 cases (56.7%) for immediate repair, 80 cases (40.7%) for early repair (P < 0.05) and in 9 cases (6.8%) for late repair (P < 0.001). CONCLUSION The timing of surgical repair for a bile duct injury sustained during a cholecystectomy influences significantly the rate of a second procedure and a late repair should be preferred option.

Laparoscopic sleeve gastrectomy: how I do it.

Laparoscopic sleeve gastrectomy (LSG) is considered a straightforward procedure but the surgical technique is one of the major determinants of the success of this procedure. We describe a 3-port approach to LSG that was adopted in 750 consecutive cases. The LSG was completed with 4 cartridges in 712 cases (95%) and was associated with a 4.8% rate of complications including a 2.4% rate of leak. The surgical technique is described in detail and the inherent advantages are discussed.

Hiatal Hernia of the Roux-en-Y Gastric Bypass Pouch 8 years After Surgery

Laparoscopic Roux-en-Y gastric bypass procedure (LRYGBP) is common in bariatric surgery. Although several complications of LRYGBP have been identified, mainly because of the complex anatomy involved in this procedure, hiatal hernia of the gastric pouch is yet to be detailed. Here, we report the case of a patient with herniation of the gastric pouch through the hiatal orifice, complicating the LRYGBP 8 years after surgery. We describe the laparoscopic repair and discuss the mechanisms leading to this rare complication.

Single-Anastomosis Pylorus-Preserving Bariatric Procedures: Review of the Literature

Single-anastomosis pylorus-preserving procedures (SAPPP) were recently introduced into bariatric surgery in order to combine the physiologic advantages of a post-pyloric reconstruction with the technical advantages of an omega loop. Surgery consists of a sleeve gastrectomy that is performed first, followed by a duodeno-enterostomy. Two main variants exist: proximal and distal SAPPP, with duodeno-jejunostomy and duodeno-ileostomy, respectively. This review describes the SAPPP reported in the literature and analyzes their outcomes in comparison with the most frequently performed bariatric techniques. Preliminary results appear as promising in terms of both safety and effectiveness on weight loss and comorbidities improvement.