David Nocca

The Effectiveness of Noninvasive Positive Pressure Ventilation to Enhance Preoxygenation in Morbidly Obese Patients: A Randomized Controlled Study

BACKGROUND: Noninvasive positive-pressure ventilation (NPPV) with pressure support-ventilation and positive end-expiratory pressure are effective in providing oxygenation during intubation in hypoxemic patients. We hypothesized administration of oxygen (O2) using NPPV would more rapidly increase the end-tidal O2 concentration (ETo2) than preoxygenation using spontaneous ventilation (SV) in morbidly obese patients. METHODS: Twenty-eight morbidly obese patients were enrolled in this prospective randomized study. Administration of O2 for 5 min was performed either with SV group or with NPPV (pressure support = 8 cm H2O, positive end-expiratory pressure = 6 cm H2O) (NPPV group). ETo2 was measured using the anesthesia breathing circuit, and is expressed as a fraction of atmospheric concentration. The primary end-point was the number of patients with an ETo2 >95% at the end of O2 administration. Secondary end-points included the time to reach the maximal ETo2 and the ETo2 at the conclusion of O2 administration. RESULTS: A larger proportion of patients achieved a 95% ETo2 at 5 min with NPPV than SV (13/14 vs 7/14, P = 0.01). The time to reach the maximal ETo2 was significantly less in the NPPV than in the SV group (185 ± 46 vs 222 ± 42 s, P = 0.02). The mean ETo2 at the conclusion of O2 administration was larger in the NPPV group than the SV group (96.9 ± 1.3 vs 94.1 ± 2.0%, P < 0.001). A modest, although significant, increase in gastric distension was observed in the NPPV group. No adverse effects were observed in either group. CONCLUSION: Administration of O2 via a facemask with NPPV in the operating room is safe, feasible, and efficient in morbidly obese patients. In this population NPPV provides a more rapid O2 administration, achieving a higher ETo2.

Capture of Viable Circulating Tumor Cells in the Liver of Colorectal Cancer Patients

BACKGROUND The incidence and number of circulating tumor cells (CTCs) in the peripheral blood of colorectal cancer patients are lower than in other cancer types, which may point to a particular biology of colorectal cancer affecting CTC detection. METHODS We detected CTCs in the peripheral and mesenteric blood of colorectal cancer patients by use of 2 independent technologies on the basis of different biological properties of colon cancer cells. Seventy-five patients diagnosed with localized (M0, n = 60) and metastatic (M1, n = 15) colorectal cancer were included. Peripheral and mesenteric blood samples were collected before tumor resection. We performed CTC enumeration with an EpCAM-independent enrichment method followed by the Epispot assay that detected only viable CK19-releasing CTCs. In parallel, we used the FDA-cleared EpCAM-dependent CellSearch® as the reference method. RESULTS The enumeration of CK19-releasing cells by the CK19-Epispot assay revealed viable CTCs in 27 of 41 (65.9%) and 41 of 74 (55.4%) (P = 0.04) patients in mesenteric and peripheral blood, respectively, whereas CellSearch detected CTCs in 19 of 34 (55.9%) and 20 of 69 (29.0%) (P = 0.0046) patients. In mesenteric blood, medians of 4 (range 0-247) and 2.7 CTCs (range 0-286) were found with Epispot and CellSearch (P = 0.2), respectively, whereas in peripheral blood, Epispot and CellSearch detected a median of 1.2 (range 0-92) and 0 CTCs (range 0-147) (P = 0.002). CONCLUSIONS A considerable portion of viable CTCs detectable by the Epispot assay are trapped in the liver as the first filter organ in CRC patients.

An endoscopic strategy for management of anastomotic complications from bariatric surgery: a prospective study

BACKGROUND Treatment of anastomotic fistulas after bariatric surgery is difficult, and they are often associated with additional surgery, sepsis, and prolonged non-oral feeding. OBJECTIVE To assess a new, totally endoscopic strategy to manage anastomotic fistulas. DESIGN Prospective study. SETTING Tertiary-care university hospital. PATIENTS This study involved 27 consecutive patients from July 2007 to December 2009. INTERVENTION This strategy involved successive procedures for endoscopic drainage of the residual cavity, diversion of the fistula with a stent, and then closure of the residual orifice with surgical clips or sealant. MAIN OUTCOME MEASUREMENTS Technical success, mortality and morbidity, migration of the stent. RESULTS Multiple or complex fistulas were present in 16 cases (59%). Endoscopic drainage (nasal-fistula drain or necrosectomy) was used in 19 cases (70%). Diversion by a covered colorectal stent was used in 22 patients (81%). To close the residual or initial opening, wound clips and glue (cyanoacrylate) were used in 15 cases (55%). Neither mortality nor severe morbidity occurred. Migration of the stent occurred in 13 cases (59%) and was treated by replacement with either a longer stent or with 2 nested stents. The mean time until resolution of fistula was 86 days from the start of endoscopic management, with a mean of 4.4 endoscopies per patient. LIMITATIONS Moderate sample size, nonrandomized study. CONCLUSION An entirely endoscopic approach to the management of anastomosing fistulas that develop after bariatric surgery--using sequential drainage, sutures, and diversion by stents--achieved resolution of the fistulas with minimal morbidity.

Migration of adjustable gastric banding from a cohort study of 4236 patients

BackgroundExperience was gained management of intra-gastric migration of adjustable gastric banding.MethodsFrom July 1996 to January 2003, 4236 patients who underwent laparoscopic adjustable gastric banding were proposed for routine follow-up. Gastrograms were performed in case of band adjustment. Radiological controls and endoscopy were performed according to symptoms.ResultsA total of 45 cases of band migration (1.6%) were diagnosed during follow-up. All but one of the migrated bands were removed laparoscopically either by a dissection outside the stomach or through a short gastrotomy. Mortality was 0% and morbidity 8% (n = 4).ConclusionThe risk of an intragastric band migration remains low in the literature but could grow on account of the longer follow-up of patients. The retrieval of the band is the gold standard and must be planned promptly or delayed according to symptoms.

Nutrient deficiencies in patients with obesity considering bariatric surgery: A cross-sectional study

BACKGROUND Nutritional deficiencies are common after bariatric surgery, but few studies have examined them preoperatively. The objective of this study was to evaluate several vitamins, nutrients, and nutritional markers and their determinants in patients with obesity considering bariatric surgery. METHODS Preoperative values of fasting plasma glucose, insulin, lipid profile, 25-hydroxyvitamin D (25(OH)D), parathyroid hormone, thyroid-stimulating hormone, calcium, phosphate, albumin, magnesium, total proteins, liver function tests, iron, ferritin, folate, vitamin A, vitamin B12, selenium, and zinc were evaluated in 267 Caucasian outpatients (74.2% women, aged 40.5±12.6 years) who were considering bariatric surgery. The determinants of nutrient variability were analyzed by linear regression for nutrients with a prevalence of deficiency>10%, i.e., serum 25(OH)D, iron, phosphate, magnesium, and vitamin A. RESULTS Prevalence of inadequate concentrations was high for 25(OH)D (67.9% with values ≤ 20 ng/mL), magnesium (35.4%), phosphate (21.6%), iron (18.8%), and vitamin A (16.9%). Multiple deficiencies were common; 28.5%, 12.1%, and 6.3% of patients had 2, 3, and 4 deficiencies, respectively. In multivariate analyses, metabolic characteristics had an important impact on deficiencies, with lower values of 25(OH)D and vitamin A with increasing body mass index, lower values of 25(OH)D and magnesium with increasing fasting plasma glucose, and a positive correlation between vitamin A and triglycerides. Elevated TSH was associated with low iron concentrations. CONCLUSION At all ages, micronutrient deficiencies were common, with high prevalence of concentration inadequacies for 25(OH)D, magnesium, phosphate, iron, and vitamin A. High body mass index and high fasting plasma glucose increased the risk of deficiencies, particularly for 25(OH)D. Preoperative screening and correction of deficiencies should be advised.

Surgical management of chronic fistula after sleeve gastrectomy

BACKGROUND There is no clear definition of the chronic leak after sleeve gastrectomy. There are several endoscopic approaches, including endoprothese, endoscopic clips, endoscopic sealing glue, or balloon dilation. In case of failure of the endoscopic treatment, a definitive surgical approach can be attempted. The objective was to evaluate the surgical treatment of chronic leak after sleeve gastrectomy. METHODS From November 2010 through March 2012, 8 patients with chronic gastric fistula after laparoscopic sleeve gastrectomy had definitive surgical repair. The initial intervention, the diagnosis and management of the fistula, and the endoscopic approach were carefully reviewed. RESULTS Five patients had their original laparoscopic sleeve gastrectomies performed at another hospital, while 3 had laparoscopic sleeve gastrectomy at our institution. The mean period of time from the diagnosis of the fistula to definitive surgical treatment was 14.4 months (range 5-44 months). Seven patients initially had surgical drainage by laparoscopy (5) and by laparotomy (2), with concomitant feeding jejunostomy in 6 patients. The endoscopic treatment consisted of endoprothese in 4 patients, endoscopic sealing glue in 2 patients, and sequential approach with glue and prosthesis in 2 other patients. One patient was treated exclusively by endoscopic approach with no surgical drainage. The surgical procedures performed for chronic fistula were gastrojejunal lateral anastomosis (4), Roux-en-Y gastric bypass (2), and gastrectomy with esojejunal anastomosis (2). Four patients presented with postoperative fistula, with a mean healing time of 32 days (range 22-63 days). No mortality was recorded. CONCLUSION In chronic forms of fistulas with no improvements by endoscopic approach, the surgical treatment can be a solution. It remains a difficult procedure with a high percentage of leakage, but this type of fistula is more easily tolerated by the patient and heals faster.

Endoscopic treatment of fistula after sleeve gastrectomy: results of a multicenter retrospective study

BACKGROUND AND STUDY AIMS Fistula is the main complication of laparoscopic sleeve gastrectomy (LSG), for which healing is difficult to achieve. The aims of the study were to evaluate the efficacy of interventional endoscopy for post-LSG fistula treatment, to evaluate various endoscopic techniques used and identify their complications, and to identify predictive factors of healing following endoscopic treatment. PATIENTS AND METHODS This retrospective multicenter study included patients with post-LSG fistula. Therapeutic procedures were evaluated, taking into account complications and healing times. Endoscopic procedures were considered to have promoted healing if no other surgical procedure was performed. Predictive factors of healing were identified by univariate and multivariate analysis. RESULTS A total of 110 patients were included, of whom 6 (5.5 %) healed spontaneously, 81 (73.6 %) healed following endoscopic treatment, and 19 (17.3 %) healed following surgery. Healing rates following endoscopic treatment were 84.4 % in the first 6 months of treatment (65/77), 52.4 % for treatment lasting 6 - 12 months (11/21), and 41.7 % after 12 months of treatment (5/12). A drainage procedure (surgical, endoscopic, or percutaneous) was performed in 92 patients (83.6 %). A total of 177 esogastric stents were placed in 88 patients (80.0 %). Surgical debridement, clip placement, glue sealing, and plug placement were also performed. Multivariate analysis identified four predictive factors of healing following endoscopic treatment: interval < 21 days between fistula diagnosis and first endoscopy (P = 0.003), small fistula (P = 0.01), interval between LSG and fistula ≤ 3 days (P = 0.01), no history of gastric banding (P = 0.04). CONCLUSION Endoscopic treatment facilitated healing of post-LSG fistula in 74 % of patients. Early endoscopic treatment increased the likelihood of success, and was most effective during the first 6 months of management. After this point, surgical treatment should be considered.

Current challenges in providing bariatric surgery in France: A nationwide study.

Abstract Bariatric surgery is a well-accepted procedure for severe and massive obesity management. We aimed to determine trends, geographical variations, and factors influencing bariatric surgery and the choice of procedure in France in a large observational study. The Health Insurance Fund for Salaried Workers (Caisse National Assurance Maladie Travailleurs Salariés) covers about 86% of the French population. The Système National d’Information Inter-régimes de l’Assurance Maladie database contains individualized and anonymized patient data on all reimbursements for healthcare expenditure. All types of primary bariatric procedures (Roux-en-Y gastric bypass [RYGB] or omega loop, adjustable gastric banding [AGB], or longitudinal sleeve gastrectomy [LSG]) performed during 2011 to 2013 were systematically recorded. Surgical techniques performed by region of residence and age-range relative risks with 95% confidence intervals of undergoing LSG or RYGB versus AGB were computed. In 2013, LSG was performed more frequently than RYGB and AGB (57% vs 31% and 13%, respectively). A total of 41,648 patients underwent a bariatric procedure; they were predominantly female (82%) with a mean (±standard deviation) age of 40 (±12) years and a body mass index ≥40 kg/m2 for 68% of them. A total of 114 procedures were performed in patients younger than 18 years and 2381 procedures were performed in patients aged 60 years and older. Beneficiaries of the French universal health insurance coverage for low-income patients were more likely to undergo surgery than the general population. Large nationwide variations were observed in the type choice of bariatric surgical procedures. Significant positive predictors for undergoing RYGB compared to those for undergoing AGB were as follows: referral to a center performing a large number of surgeries or to a public hospital, older age, female gender, body mass index ≥50 kg/m2, and treatment for obstructive sleep apnea syndrome, diabetes, or depression. Universal health insurance coverage for low-income patients was inversely correlated with the probability of RYGB. Differences in access to surgery have been observed in terms of the patients profile, geographical variations, and predictors of types of procedures. Several challenges must be met when organizing the medical care of this growing number of patients, when delivering surgery through qualified centers while assuring the quality of long-term follow-up for all patients.

Association Between Bariatric Surgery and Rates of Continuation, Discontinuation, or Initiation of Antidiabetes Treatment 6 Years Later

Importance Few large-scale long-term prospective cohort studies have assessed changes in antidiabetes treatment after bariatric surgery. Objective To describe the association between bariatric surgery and rates of continuation, discontinuation, or initiation of antidiabetes treatment 6 years after bariatric surgery compared with a matched control obese group. Design, Setting, and Participants This nationwide observational population-based cohort study extracted health care reimbursement data from the French national health insurance database from January 1, 2008, to December 31, 2015. All patients undergoing primary bariatric surgery in France between January 1 and December 31, 2009, were matched on age, sex, body mass index category, and antidiabetes treatment with control patients hospitalized for obesity in 2009 with no bariatric surgery between 2005 and 2015. Exposures Bariatric surgery, including adjustable gastric banding (AGB), gastric bypass (GBP), and sleeve gastrectomy (SG). Main Outcome and Measure Reimbursement for antidiabetes drugs. Mixed-effects logistic regression models estimated factors of discontinuation or initiation of antidiabetes treatment over a period of 6 years. Results In 2009, a total of 15 650 patients (mean [SD] age, 38.9 [11.2] years; 84.6% female; 1633 receiving antidiabetes treatment) underwent primary bariatric surgery, with 48.5% undergoing AGB, 27.7% undergoing GBP, and 22.0% undergoing SG. Among patients receiving antidiabetes treatment at baseline, the antidiabetes treatment discontinuation rate was higher 6 years after bariatric surgery than in controls (−49.9% vs −9.0%, P < .001). In multivariable analysis, the main predictive factors for discontinuation were the following: GBP (odds ratio [OR], 16.7; 95% CI, 13.0-21.4), SG (OR, 7.30; 95% CI, 5.50-9.50), and AGB (OR, 4.30; 95% CI, 3.30-5.60) compared with no bariatric surgery, as well as insulin use (OR, 0.17; 95% CI, 0.13-0.22), dual therapy without insulin (OR, 0.38; 95% CI, 0.32-0.45) vs monotherapy, lipid-lowering treatment (OR, 0.76; 95% CI, 0.63-0.91), antidepressant treatment (OR, 0.67; 95% CI, 0.55-0.81), and age (OR, 0.96; 95% CI, 0.95-0.97) per year. For patients without antidiabetes treatment at baseline, the 6-year antidiabetes treatment initiation rate was much lower after bariatric surgery than in controls (1.4% vs 12.0%, P < .001). In multivariable analysis, protective factors were GBP (OR, 0.06; 95% CI, 0.04-0.09), SG (OR, 0.08; 95% CI, 0.06-0.11), and AGB (OR, 0.16; 95% CI, 0.14-0.20) vs controls, and risk factors were as follows: body mass index category (OR, 2.04; 95% CI, 1.68-2.47 for ≥50.0 vs 30.0-39.9 and OR, 1.68; 95% CI, 1.49-1.90 for 40.0-49.9 vs 30.0-39.9), antihypertensive treatment (OR, 1.49; 95% CI, 1.33-1.67), low income (OR, 1.43; 95 % CI, 1.26-1.62), and age (OR, 1.04; 95 % CI, 1.03-1.05) per year. Conclusions and Relevance Bariatric surgery was associated with a significantly higher 6-year postoperative antidiabetes treatment discontinuation rate compared with baseline and with an obese control group without bariatric surgery.

To What Extent Does Posthospital Discharge Chemoprophylaxis Prevent Venous Thromboembolism After Bariatric Surgery?: Results From a Nationwide Cohort of More Than 110,000 Patients

Objective: The aim of the present study was to assess the incidence, risk factors, and the impact of posthospital discharge (PHD) chemoprophylaxis on venous thromboembolism (VTE) in patients undergoing bariatric surgery (BS). Background: VTE is a major concern after BS, especially during the PHD period. No large-scale study has previously focused on the clinical value of PHD chemoprophylaxis. Methods: In this nationwide observational population-based cohort study, all data from patients undergoing BS were extracted from the French National Health Insurance database (SNIIRAM) from 1st January 2012 to 31st September 2014. Logistic regression models were used to compute odds ratios for potential risk factors for VTE occurring within 90 postoperative days (PODs). The association between use of PHD chemoprophylaxis (heparin) and VTE was also assessed. Results: The majority (56%) of the 110,824 patients had sleeve gastrectomy. VTE rates during the first 30 and 90 PODs were 0.34% and 0.51%, respectively. On multivariate analyses, the major risk factors for VTE during the first 90 PODs were history of VTE [odds ratio = 6.33 95% confidence interval (4.44–9.00)], postoperative complications [9.23 (7.30–11.70)], heart failure [2.45 (1.48–4.06)], and open surgery [2.38 (1.59–3.45)]. PHD chemoprophylaxis was delivered to 75% of patients. No use of PHD chemoprophylaxis [1.27 (1.01–1.61)] was an independent predictive factor of VTE during the first 90 PODs [in the gastric bypass group: 1.51 (1.01–2.29)). Conclusions: In the modern era of BS, this nationwide study shows a non-negligible rate of VTE especially after sleeve gastrectomy, depending on the individual risk level. Use of PHD chemoprophylaxis may decrease the risk of PHD VTE.