Claude Polliand

Tracheal intubation of morbidly obese patients: a randomized trial comparing performance of Macintosh and Airtraq™ laryngoscopes

BACKGROUND The Airtraq laryngoscope is designed to allow visualization of the glottis without alignment of the oral, pharyngeal, and laryngeal axes. We hypothesized that this new airway device would facilitate tracheal intubation of morbidly obese patients. We compared tracheal intubation performance of standard Macintosh laryngoscope with the Airtraq laryngoscope in morbidly obese patients. METHODS One hundred and six consecutive ASA I-III morbidly obese patients undergoing surgery were randomized to intubation with the Macintosh laryngoscope or the Airtraq laryngoscope. Induction of anaesthesia was standardized. If tracheal intubation failed within 120 s with the Macintosh or Airtraq , laryngoscopes were switched. Success rate, SpO2, duration of tracheal intubation, and quality of airway management were evaluated and compared between the groups. RESULTS Preoperative characteristics of the patients were similar in both groups. In the Airtraq group, tracheal intubation was successfully carried out in all patients within 120 s. In the Macintosh laryngoscope group, six patients required intubation with the Airtraq laryngoscope. The mean (SD) time taken for tracheal intubation was 24 (16) and 56 (23) s, respectively, with the Airtraq and Macintosh laryngoscopes, (P<0.001). SpO2 was better maintained in the Airtraq group than in the Macintosh laryngoscope group with one and nine patients, respectively, demonstrating drops of SpO2 to 92% or less (P<0.05). CONCLUSIONS In this study, the Airtraq laryngoscope shortened the duration of tracheal intubation and prevented reductions in arterial oxygen saturation in morbidly obese patients.

Video-Assisted Versus Conventional Tracheal Intubation in Morbidly Obese Patients

BackgroundWe compared tracheal intubation characteristics and arterial oxygenation quality during airway management of morbidly obese patients whose trachea was intubated under video assistance with the LMA CTrach™ (SEBAC, Pantin, France) or the Airtraq™ laryngoscope (VYGON, Écouen, France) with that of the conventional Macintosh laryngoscope.MethodsAfter standardized induction of anesthesia, 318 morbidly obese patients scheduled for elective morbid obesity surgery received tracheal intubation with the LMA CTrach™, the Airtraq™ laryngoscope, or the conventional Macintosh laryngoscope. Duration of apnea, time to tracheal intubation, and oxygenation quality during airway management were compared between the LMA CTrach™ and the laryngoscope groups.ResultsPatients’ characteristics were similar in the three groups. The success rate for tracheal intubation was 100% with the LMA CTrach™ and the Airtraq™ laryngoscope. One patient of the Macintosh laryngoscope group received LMA CTrach™ intubation because of early arterial oxygen desaturation associated with unstable facemask ventilation. The duration of apnea was shorter with the LMA CTrach™ than that of the Airtraq™ laryngoscope and the Macintosh laryngoscope. The duration tracheal intubation was shorter with the Airtraq™ laryngoscope than with the Macintosh laryngoscopes and the LMA CTrach™. During airway management, arterial oxygenation was of better quality with the LMA CTrach™ and the Airtraq™ laryngoscope than that of the Macintosh laryngoscope.ConclusionBecause LMA CTrach™ promoted short apnea time and the Airtraq™ laryngoscope allowed early definitive airway, both video-assisted tracheal intubation devices prevented most serious arterial oxygenation desaturation evidenced during tracheal intubation of morbidly obese patients with the conventional Macintosh laryngoscope.

Quality of life after laparoscopic gastric banding: Prospective study (152 cases) with a follow-up of 2 years.

To evaluate influence of laparoscopic gastric banding (LGB) on quality of life (QOL) in patients with morbid obesity. Laparoscopic adjustable gastric banding is a popular bariatric operation in Europe. The objectives of surgical therapy in patients with morbid obesity are reduction of body weight, and a positive influence on the obesity-related comorbidity as well the concomitant psychologic and social restrictions of these patients. In a prospective clinical trial, development of the individual patient QOL was analyzed, after LGB in patients with morbid obesity. From October 1999 to January 2001, 152 patients [119 women, 33 men, mean age 38.4 y (range 24 to 62), mean body mass index 44.3 (range 38 to 63)] underwent evaluation for LGB according the following protocol: history of obesity; concise counseling of patients and relative on nonsurgical treatment alternatives, risk of surgery, psychologic testing, questionnaire for eating habits, necessity of lifestyle change after surgery; medical evaluation including endocrinologic and nutritionist work-up, upper GI endoscopy, evaluation of QOL using the Gastro Intestinal Quality of Life Index (GIQLI). Decision for surgery was a multidisciplinay consensus. This group was follow-up at least 2 years, focusing on weight loss and QOL. Mean operative time was 82 minutes; mean hospital stay was 2.3 days and the mean follow-up period was 34 months. The BMI dropped from 44.3 to 29.6 kg/m2 and all comorbid conditions improved markedly: diabetes melitus resolved in 71% of the patients, hypertension in 33%, and sleep apnea in 90%. However, 26 patients (17%) had late complications requiring reoperation. Preoperative global GIQLI score was 95 (range 56 to 140), significant different of the healthy volonteers score (120) (70 to 140) P<0.001. Correlated with weight loss (percentage loss of overweight and BMI), the global score of the group increased to 100 at 3 months, 104 at 6, 111 at 1 year to reach 119 at 2 years which is no significant different of healthy patients. Analyzing the subscale, physical condition, emotional status, and social integration increased significantly (P<0.001) from preoperative to end of follow-up. Digestive symptoms were not modified. In case of failure of the procedure (10.5%) global Giqli score is not modified. Patients who have required successfull revisional surgery for late complications (6.5%) have an excellent QOL outcome that are not different from the whole group. Together with a satisfactory reduction of the excess overweight, laparoscopic gastric banding may lead in a carefully selected population of patients with morbid obesity to a significant improvment of patient QOL, in at least 2 years follow-up.

Laparoscopic appendectomies: Retrospective study of 2074 cases

Purpose To determine feasibility and safety of laparoscopic appendectomy (LA). Patients From January 1991 to June 2006, 2209 consecutive patients underwent appendectomy; for 2074 patients, appendectomy was performed laparoscopically. One thousand and fifty (53%) were women; mean age was 30.8 (11 to 96) years. Mean body mass index was 23.6 (18 to 58 kg/m2). Mean American Society of Anesthesiology score was 1.3 (I to III). Results Mean operating time was 52 minutes (15 to 200). Conversion to open appendectomy occurred for 84 patients (3.6%) mainly for acute or generalized peritonitis, abscess, or adhesion. Mean hospital stay was 3.75 (1 to 27) days. There was no mortality. Morbidity occurred in 4.5% of the patients: parietal (1.15%), peritoneal complications (1.1%), and others (2.25%). Additional interventions were required for 30 patients (1.5%) primarily for residual abscesses. In this study, 10.9% (n=226) of the specimens were considered normal by the pathologist. In 3.9% (77 cases), laparoscopy did not find any cause for nonspecific abdominal pain. In these cases, appendix was not removed. Conclusions LA is technically feasible and safe. Diagnostic laparoscopy is recommended in cases suspicious for acute appendicitis. Laparoscopy permits a complete exploration of the abdominal cavity, helps to localize the appendix, allows for the eliminations of other diagnoses when the appendix is normal, and to facilitate a better peritoneal lavage in case of peritonitis. It is recommended to perform LA routinely in young women and obese. Although advantages of LA still need to be evaluated, in view of the excellent results, we have decided to perform it routinely. We also recommend not removing macroscopically normal appendices discovered during diagnostic laparoscopy for abdominal pain of unexplained origin.

Two-step conversion surgery after failed laparoscopic adjustable gastric banding. Comparison between laparoscopic Roux-en-Y gastric bypass and laparoscopic gastric sleeve

BACKGROUND Despite its worldwide popularity, laparoscopic adjustable gastric banding (LAGB) requires revisional surgery for failures or complications, in 20-60% of cases. The purpose of this study was to compare in terms of efficacy and safety, the conversion of failed LAGB to laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy. (LSG). METHODS The bariatric database of our institution was reviewed to identify patients who had undergone conversion of failed LAGB to LRYGB or to LSG, from November 2007 to June 2012. RESULTS A total of 108 patients were included. Of these, 74 (68.5%) underwent conversion to LRYGB and 34 to LSG. All of the procedures were performed in 2-stage and laparoscopically. The mean follow-up for the LRYGB group was 29.1±17.9 months while for the LSG patients was 24.2±14.3 months. The mean body mass index (BMI) prior LRYGB and LSG was 45.6±7.8 and 47.5±5.6 (P = .09), respectively. Postoperative complications occurred in 16.2% of the LRYGB patients and in 2.9% of the LSG group (P = .04). Mean percentage of excess weight loss was 59.9%±16.2% and 70.2%±16.7% in LRYGB, and it was 52.2%±11.4% and 59.9%±14.4% in LSG at 12 months (P = .007) and 24 months (P = .01) after conversion. CONCLUSION In this series, LRYGB and LSG are both effective and adequate revisional procedure after failure of LAGB. While LRYGB seems to ensure greater weight loss at 24 months follow-up, LSG is associated with a lower postoperative morbidity.

Laparoscopic resection of low rectal cancer with a mean follow-up of seven years.

The role of laparoscopic surgery in the management of cancer of the rectum remains controversial. The main concern is the risk of port-site metastasis and neoplastic dissemination. The aim of this study was to evaluate prospectively 29 patients who underwent laparoscopic resection with total mesorectum excision for lower rectal carcinoma with a mean follow-up of 7 years. From January 1993 to December 1998, 29 patients with proven low (<10 cm from the anal verge) rectal cancer were operated by a laparoscopic approach. They were followed up at 1-, 3-, and then every 6-month intervals, postoperatively for an average of 7 years. Mean operative time was 157 ± 46 minutes. The conversion rate was 13.7% (4 cases): 1 for tumor invasion of adjacent structures, 2 for inadequate margins of resection, and 1 for locally advanced cancer. First flatus occurred after 37.3 ± 11.5 hours, and oral feeding started at 48.3 ± 23 hours postoperatively. The length of the suprapubic incision for extraction of the specimen was 5.6 ± 1.7 cm. Hospital stay was 7.2 ± 3.0 days. There were no deaths. The morbidity rate was 14.8%. Length of the specimen, lateral and distal margins, and the number of lymph nodes resected were comparable to those of an open surgical approach. The average postoperative follow-up was 7 years (5-10 years). The late complication rate was 3.7%. There were no port-site metastases. Five-year recurrence rates were 0%, 22%, and 37% for Dukes A, B, and C cancers, respectively. The 5-year survival rate was 100% for Dukes A, 89% for B, and 50% for C. Laparoscopic resection for low rectal cancer with total mesorectum excision can be performed with the same oncologic principles, low morbidity, and long-term complications. Five-year survival and recurrence rates are comparable to those of open surgery.

Hepatic endometrioma: a case report and review of the literature: report of a case

Hepatic endometriosis has an extremely rare occurrence characterized by the presence of ectopic endometrium in the liver. A diagnosis of hepatic endometriosis is established after surgery. A 51-year-old multiparous female was referred to our unit for investigation of a liver tumor. The patient reported a 6-month history of epigastric pain and vomiting. She had undergone conservative hysterectomy for uterine leiomyomas several years earlier. The results of liver function tests and the levels of tumor markers (CA 19.9, CEA, CA125, αFP) were normal. Radiological imaging (USS, CT and MRI) suggested the presence of liver cystadenoma, liver cystadenocarcinoma or cystic metastasis of the liver in the left liver lobe extending to the diaphragm with left hepatic vein compression. Laparotomy was performed. The intraoperative frozen sections suggested a diagnosis of endometriosis. Anatomical resection was performed, including left lobectomy with diaphragm resection. The final histology confirmed the presence of hepatic endometrioma without malignant transformation. Fourteen cases of hepatic endometrioma have been described in the medical literature. We herein report the 15th case. Making a preoperative diagnosis of hepatic endometriosis is very difficult, despite conducting a complete investigation, in the absence of clinical and radiological characteristics. The diagnosis is made according to a histological examination of the whole surgical sample.

Prolonged paradoxical response to anti-tuberculous treatment after infliximab

A 56-year-old woman with ankylosing spondylitis, treated for 3 months with infliximab, developed miliary tuberculosis with mediastinal lymphadenopathies and brain and splenic lesions. After initial improvement under anti-tuberculous therapy, she suffered an unexpectedly prolonged paradoxical worsening with several episodes of lymphadenopathy, including life-threatening ones, over a period of more than 14 months of follow-up. The outcome was favorable as a result of corticosteroid and surgical treatments. This phenomenon reflects a paradoxical reaction precipitated by infliximab withdrawal.

Existe-t-il des facteurs prédictifs de succès dans le traitement de l'obésité morbide par anneau périgastrique modulable ? Étude prospective

Background. – Surgical treatment of morbid obesity by perigastric adjustable banding give at mid term follow up, contrasted results which associate succes, failure and intermediate situations. Aims. – The objective of this work was to prospectively validate predicting items that would predict success in the surgical treatment of morbid obesity by adjustable gastric banding. Material and methods. – Eighty patients with morbid obesity have been treated with adjustable gastric banding. Seventy one women, and nine men with a mean age of 37.8 years (20–59) with a mean follow up of 17 months (12–52). They have been classified in three groups: success, failure, and intermediate results. Uni- and multivariate analysis was performed on six criterions: age, sex, professional activity, metabolic disorders, lengh of obesity and body mass index (BMI). Results. – Concerning age, sex, professional activity, metabolic disorders, and lengh of obesity, there was no difference between the three groups. However, a BMI more than 50 kg/m2 has a strong predictive value. Patients called super obese: BMI >50 has a high rate of failure (64%) even the weight loss is ofen important in absolute value, but the BMI a the follow up remain high and more than 40. In this situation: gastric banding does not seem a good treatment because it does not protect these patients against the lethal risk of their comorbidities. Conclusion. – In this study, there is not a specific candidate « profile » to a successful treatment of morbid obesity by adjustable gastric banding. Meanwhile the initial BMI appear to be a predictive factor of success or failure. In the case of patients with high BMI >50 (super obese) Gastric banding did not seen to be a good treatment and an other technical approach (gastric by pass) must be discuss.

Laparoscopic sleeve gastrectomy after failed gastric banding: is it really effective? Six years of follow-up

BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has become a valuable surgical option to rescue laparoscopic adjustable gastric banding (LAGB) failures. OBJECTIVES The aim of this study was to determine whether conversion to LSG after failed LAGB (CLSG) is a well-tolerated and effective rescue procedure compared with primary LSG (PLSG) in the long term. SETTING University hospital, France. METHODS A retrospective review of data concerning consecutive patients receiving a LSG between February 2008 and December 2014 was conducted. Mortality, postoperative complications, and weight loss outcomes were analyzed. RESULTS Of 701 LSG, 601 (85.7%) were PLSG and 100 (14.3%) were CLSG. The mortality rate was 0%. Overall morbidity was comparable between the primary and conversion group (10% versus 6%, P = .27). The mean percentage of excess weight loss at 3, 36, and 72 months was 34.9%, 72.1%, and 57.2% after PLSG and 22.6%, 51.2% and 29.8% after CLSG (P<.05). The failure rate (mean percentage of excess weight loss<50%) was higher in the CLSG group during the first 5 postoperative years (P < .001) with more than two thirds of the CLSG considered as having failed at 60 months. Patients who underwent band ablation as a result of insufficient weight loss or weight regain presented the worst results after conversion to LSG. CONCLUSION In this study, the conversion of failed LAGB to LSG in 2 steps indicated a safety profile comparable to that of primary LSG but was significantly less effective from the early postoperative course (3 mo) up to 6 years postoperatively. CLSG may not be the best option because a third operation may be needed as a result of insufficient weight loss.