Denis Chosidow

Laparoscopic sleeve gastrectomy as an initial bariatric operation for high-risk patients: initial results in 10 patients.

Background: The outcomes and initial results of laparoscopic sleeve gastrectomy were evaluated. Methods: A prospective study of the initial 10 patients who underwent laparoscopic sleeve gastrectomy (LSG) was performed. Study endpoints included operative time, complication rates, hospital length of stay and percentage of excess weight loss (%EWL). Results: There were 5 women and 5 men, with mean age 43 years (range 31 to 52). Mean preoperative weight was 182 kg (range 125-247 kg), with mean preoperative BMI 64 (range 61-80). Indication for LSG was related to BMI in all patients. 1 patient had previous restrictive bariatric surgery. Mean operative time was 2 hours (range 1.5-2.5). No patient required conversion. There were no postoperative complications nor mortality. Median hospital stay was 7.2 days. Average %EWL and BMI at 1 year were 51% and 23 kg/m2, respectively. Conclusion: LSG can be safely integrated into a bariatric surgical program with good results in terms of weight loss and quality of life. LSG can be a firststage procedure before gastric bypass or duodenal switch or a one-stage restrictive procedure if longterm results are good. LSG should be considered as a surgical option in the bariatric field.

Laparoscopic Conversion of Laparoscopic Gastric Banding to Roux-en-Y Gastric Bypass: a Review of 70 Patients

Background: The feasibility and outcomes of conversion of laparoscopic adjustable gastric banding (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGBP) was evaluated. Methods: From November 2000 to March 2004, all patients who underwent laparoscopic conversion of LAGB to LRYGBP were retrospectively analyzed. The procedure included adhesiolysis, resection of the previous band, creation of an isolated gastric pouch, 100-cm Roux-limb, side-to-side jejuno-jejunostomy, and end-to-end gastro-jejunostomy. Results: 70 patients (58 female, mean age 41) with a median BMI of 45±11 (27-81) underwent attempted laparoscopic conversion of LAGB to an RYGBP. Indications for conversion were insufficient weight loss or weight regain after band deflation for gastric pouch dilatation in 34 patients (49%), inadequate weight loss in 17 patients (25%), symptomatic proximal gastric pouch dilatation in 15 patients (20%), intragastric band migration in 3 patients (5%), and psychological band intolerance in 1 patient. 3 of 70 patients (4.3%) had to be converted to a laparotomy because of severe adhesions. Mean operative time was 240±40 SD min (210-280). Mean hospital length of stay was 7.2 days. Early complication rate was 14.3% (10/70). Late major complications occurred in 6 patients (8.6%). There was no mortality. Median excess body weight loss was 70±20%. 60% of patients achieved a BMI of <33 with mean follow-up 18 months. Conclusion: Laparoscopic conversion of LAGB to RYGBP is a technically challenging procedure that can be safely integrated into a bariatric treatment program with good results. Short-term weight loss is very good.

Laparoscopic gastric bypass versus laparoscopic adjustable gastric banding in the super-obese: a comparative study of 290 patients.

Background: Controversy exists regarding the best surgical treatment for super-obesity (BMI >50 kg/m 2 ). The two most common bariatric procedures performed worldwide are laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGBP). We undertook a retrospective single-center study to compare the safety and efficacy of these two operations in super-obese patients. Methods: 290 super-obese patients underwent laparoscopic bariatric surgery: 179 LAGB and 111 LRYGBP. Results: There were one death in both groups. The early complication rate was higher in the LAGB group (10% vs 2.8%, P<0.01). Late complication rate was higher in the LAGB group (26% vs 15.3%, P<0.05). Operating time and hospital stay were significantly higher in the LRYGBP group. LRYGBP had significantly better excess weight loss than LAGB (63% vs 41% at 1 year, and 73% vs 46% at 2 years), as well as lower BMI than LAGB (35 vs 41 at 18 months). Conclusion: LRYGBP results in significantly greater weight loss than LAGB in super-obese patients, but is associated with a higher early complication rate.

Rhabdomyolysis after Laparoscopic Bariatric Surgery

Background: Postoperative rhabdomyolysis is an uncommon event. The aim of this study was to determine the incidence of rhabdomyolysis following laparoscopic obesity surgery. Methods: Rhabdomyolysis was studied prospectively. Over a 6-month period, 66 consecutive patients underwent bariatric surgery (gastric banding (n=50) and gastric bypass (n=16)). All patients underwent laparoscopic procedures. A range of blood tests, including serum creatine phosphokinase (CPK) level and serum creatinine, were systematically performed before surgery, and on the first and third day postoperatively. Rhabdomyolysis was defined as a postoperative CPK level >1,050 IU/L. Results: Serum CPK was noted to increase significantly postoperatively to >1,050 units in 3 patients (6%) in the adjustable banding group and 12 patients (75%) in the gastric bypass group (P <0.01). In the bypass group, 4 patients (25%) had a serum CPK level >10,000 IU/L, but there were none in the gastric banding group. All patients with CPK level >10,000 IU/L had BMI >60 kg/m2. No patients experienced acute renal failure. Conclusion: Rhabdomyolysis occurred in 22.7 % of 66 consecutive patients undergoing laparoscopic bariatric surgery. Risk factors were identified: massive obesity and long duration of the operation. Early diagnosis may have significant impact on outcome by preventing or reducing the severity of complications from rhabdomyolysis. CPK level should be performed systematically after obesity surgery.

Risk factors for multidrug resistant bacteria and optimization of empirical antibiotic therapy in postoperative peritonitis

IntroductionThe main objective was to determine risk factors for presence of multidrug resistant bacteria (MDR) in postoperative peritonitis (PP) and optimal empirical antibiotic therapy (EA) among options proposed by Infectious Disease Society of America and the Surgical Infection Society guidelines.MethodsOne hundred patients hospitalised in the intensive care unit (ICU) for PP were reviewed. Clinical and microbiologic data, EA and its adequacy were analysed. The in vitro activities of 9 antibiotics in relation to the cultured bacteria were assessed to propose the most adequate EA among 17 regimens in the largest number of cases.ResultsA total of 269 bacteria was cultured in 100 patients including 41 episodes with MDR. According to logistic regression analysis, the use of broad-spectrum antibiotic between initial intervention and reoperation was the only significant risk factor for emergence of MDR bacteria (odds ratio (OR) = 5.1; 95% confidence interval (CI) = 1.7 - 15; P = 0.0031). Antibiotics providing the best activity rate were imipenem/cilastatin (68%) and piperacillin/tazobactam (53%). The best adequacy for EA was obtained by combinations of imipenem/cilastatin or piperacillin/tazobactam, amikacin and a glycopeptide, with values reaching 99% and 94%, respectively. Imipenem/cilastin was the only single-drug regimen providing an adequacy superior to 80% in the absence of broad spectrum antibiotic between initial surgery and reoperation.ConclusionsInterval antibiotic therapy is associated with the presence of MDR bacteria. Not all regimens proposed by Infectious Disease Society of America and the Surgical Infection Society guidelines for PP can provide an acceptable rate of adequacy. Monotherapy with imipenem/cilastin is suitable for EA only in absence of this risk factor for MDR. For other patients, only antibiotic combinations may achieve high adequacy rates.

Regulation of peritoneal and systemic neutrophil-derived tumor necrosis factor-α release in patients with severe peritonitis : Role of tumor necrosis factor-α converting enzyme cleavage

Objective:Polymorphonuclear neutrophil (PMN) influx and peritoneal tumor necrosis factor (TNF)-α production are key host defense mechanisms during peritonitis. The aim of this study was to explore the potential interactions between TNF-α production and TNF-α converting enzyme (TACE) expression by PMN in the blood and peritoneum of patients with severe peritonitis. Design:A prospective study. Setting:A surgical adult intensive care unit in a university hospital. Patients:A total of 29 consecutive immunocompetent patients with severe sepsis within 48 hrs of onset were enrolled and underwent laparotomy for a diffuse secondary peritonitis. Thirteen volunteers served as controls. Measurements:Blood and peritoneal fluid recovered during laparotomy were analyzed and compared for 1) soluble TNF-α, soluble L-selectin, and type I and II TNF-α receptor levels; 2) PMN membrane TNF-α, membrane L-selectin, and TACE expression (flow cytometry); and 3) TNF-α production by cultured PMN. Correlations between these forms of PMN-derived TNF-α and the severity of the peritonitis and patient’s outcome were investigated. Main Results:Elevated soluble TNF-α levels in both plasma and peritoneal fluid from the patients were found, together with decreased expression of membrane TNF-α and TACE up-regulation at the PMN surface. Soluble L-selectin and type I and II TNF receptors were highly released, suggesting also the role of TACE. In contrast, the capacity of both blood and peritoneal PMN to synthesize TNF-α in vitro, in optimal conditions of stimulation (lipopolysaccharide + interferon-γ), was impaired as compared with controls’ blood PMN. Regulation of PMN-derived TNF-α was similar in the two compartments, but responses were more pronounced in the peritoneum. TACE up-regulation at the surface of blood-derived PMN correlated with the Sequential Organ Failure Assessment score and vital outcome. Conclusion:These human data demonstrate that mTACE is up-regulated at the PMN surface during severe peritonitis. This finding could be related to a paracrine regulatory loop involving some TACE substrates such as TNF-α, L-selectin, and TNF receptors.

Hepatic portal gas due to gastro-jejunal anastomotic leak after laparoscopic gastric bypass.

Gastrointestinal complications after laparoscopic Roux-en-Y gastric bypass (LRYGBP) are not uncommon. Leakage of the gastro-jejunal anastomosis is the main early surgical complication of LRYGBP. Hepatic portal venous gas (HPVG) has been described in association with a variety of pathologic conditions. HPVG is a potentially life-threatening condition due to its etiology, with a global survival rate of <25%. We present a case of gastro-jejunal anastomotic leak associated with HPVG after LRYGBP.

Gastrojejunostomy stricture rate: comparison between antecolic and retrocolic laparoscopic Roux-en-Y gastric bypass

BACKGROUND Roux-en-Y gastric bypass procedure is an effective treatment for morbid obesity. One of the most frequent complications after this operation is the appearance of a gastrojejunal anastomotic stricture. Mechanisms underlying the development of such complication are unclear. OBJECTIVE The aim of the present retrospective study was to compare the rates of gastrojejunostomy stricture between the antecolic and retrocolic technique in a large cohort of patients undergoing Roux-en-Y gastric bypass for morbid obesity, with the same gastrojejunal anastomotic technique. SETTING University Hospital, France. METHODS From November 2000 to March 2012, 1500 patients underwent laparoscopic Roux-en-Y gastric bypass. The antecolic and the retrocolic technique were used in respectively 572 and 928 consecutive patients. All procedures were performed using a circular stapled gastrojejunostomy and absorbable sutures. RESULTS There was no significant difference with respect to gender, age, body mass index, and obesity related co-morbidities between both groups. Patients were followed for 24-146 months (mean 67.5 mo). Fifty-one patients developed a gastrojejunal stricture (3.4%), 37 in the antecolic group (6.5%) and 14 in the retrocolic group (1.5%). The difference was significant (P< .0001). The mean time to onset of gastrojejunal stricture symptoms after surgery was 1 month, ranging from 1 to 3 months. All patients were successfully treated using Savary-Gilliard dilatators. All patients with a gastrojejunal stricture were followed up for a minimum of 36 months. No recurrence was observed and no revisional surgery was needed. Weight loss was similar in patients who developed an anastomotic stricture compared with those without stricture. In the antecolic group internal hernia occurred in 12 of the 110 with no closure of mesenteric defects and in 8 of the 462 (1.7%) with defects closed. In the retrocolic group, 11 patients (1.2%) developed an internal hernia. CONCLUSIONS A significant lower gastrojejunal stricture rate was observed in the retrocolic group, with no increased risk of internal hernia, when mesenteric defects were closed. The antecolic technique seems to be a risk factor for gastrojejunal stricture development after laparoscopic gastric bypass.

Diagnosis and management of the postoperative surgical and medical complications of bariatric surgery

Perioperative complications following bariatric surgery (BS) have been poorly analysed and their management is not clearly assessed. The associated frequency of ICU admission is difficult to estimate. Among surgical complications, digestive perforations are the most frequent. The most common postoperative complications of sleeve gastrectomy are fistulas, but bleeding on the stapling line is also commonly reported. Complication rates are higher after Roux-en-Y gastric bypass, mainly due to anastomotic leaks. Medical complications are mainly thromboembolic or respiratory complications. All these surgical and medical complications are not easily detected; clinical signs can be atypical or insidious, often resulting in delayed management. Respiratory signs can be predominant and lead erroneously to pulmonary or thromboembolic diseases. Diagnostic criteria are based on minor clinical signs, tachycardia being probably the most frequent one. Lately, complications are revealed by haemodynamic instability, respiratory failure or renal dysfunction and radiographic findings. Management decision according to these abnormal signs is based on a combined multidisciplanary approach including surgical and/or endoscopic procedures and medical care, depending on the nature and severity of the surgical complication. Medical management is based on supportive ICU care of organ dysfunctions, curative anticoagulation if required, nutritional support, and appropriate anti-infective therapy. Pharmacological data are limited in morbidly obese patients and the appropriate doses are debated, especially for anti-infective agents. Complicated BS cases have a poor outcome, probably largely related to delayed diagnosis and reoperation.

Classification, surgical management and outcomes of patients with gastrogastric fistula after Roux-En-Y gastric bypass

BACKGROUND Gastrogastric fistula (GGF) is a known complication after Roux-en-Y gastric bypass that can lead to marginal ulceration (MU) and failure of weight loss. OBJECTIVES To describe our experience with GGF management and propose a classification of GGF based on its anatomic location. SETTING University hospital, France. METHODS After internal review board approval, data from all patients with a GGF were reviewed. GGF was classified as type 1 when located in the proximal part of the gastric pouch and type 2 when located near the gastrojejunostomy. RESULTS Nine patients developed a GGF (.5%). GGF symptoms included epigastric pain (78%), vomiting (11%), gastrointestinal bleeding (11%), and weight regain (44%). Upper contrast study identified GGF in all patients. Upper endoscopy confirmed GGF in 6 patients, all with type 2. Eight patients required revisional surgery. Patients with type 1 GGF (n = 3) had excision of the fistulous tract. Patients with type 2 GGF (n = 5) had associated revision of the gastrojejunostomy. Mean operative time was significantly longer for type 2 GGF. The mean follow-up was 43 months, with no patient lost. One patient developed a recurrent MU requiring iterative revision. After that, all revisional patients were symptom free and the mean body mass index was 35.3±9.5 kg/m². CONCLUSION Weight regain and epigastric pain with or without associated MU are the most common signs of GGF. Combining upper gastrointestinal endoscopy and contrast study is the best method to confirm the diagnosis. Surgical treatment should be tailored to both GGF location and status of the gastrojejunostomy. Based on its anatomic location, GGF classification could serve as a working basis to compare different surgical approaches.