Francesco Martini

Natural History of Adjustable Gastric Banding: Lifespan and Revisional Rate: A Nationwide Study on Administrative Data on 53,000 Patients.

Objective: The aim of this study was to analyze the adjustable gastric banding (AGB) natural history on a national basis. Background: Adjustable gastric banding represented the most common bariatric procedure in France until 2010. Since then, the number of AGBs has decreased and the rate of band removal and revisional surgeries has progressively increased. Methods: For analysis, we included all adult patients operated on with AGB in France between 2007 and 2013. Data were extracted from a national administrative database (“Programme De Médicalisation des Systèmes d’Information,” PMSI), which is an exhaustive source of all surgical procedures performed in France. The Cox proportional hazard model was used to test univariate and multivariate associations with band survival and revisional rate. To control for center-specific effects, we performed a frailty analysis, in which each center was assumed to have a random effect indicating the possibility of different baseline risks for patients at different centers. Results: During the study period, 52,868 patients underwent AGB, and 10,815 bands were removed. The removal rate at 5, 6, and 7 years was 28%, 34%, and 40%, respectively. Female sex, body mass index >50 kg/m2, type 2 diabetes, hypertension, dyslipidemia, and sleep apnea were found to be significantly associated with band removal by multivariate analysis. A significant center effect was also found, but this did not change the impact of the highly significant factors already identified. After band removal, the median time to revisional surgery was 1 year (95% confidence interval 1.0–1.1) and the conversion rate at 7 years was 71%. Conclusions: With a removal rate of about 6% annually and the need for revisional surgery for more than two-thirds of patients after removal, AGB does not appear to provide a long-term solution for obesity.

Laparoscopic conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: indications and preliminary results

BACKGROUND Laparoscopic sleeve gastrectomy (SG) has gained popularity as a standalone procedure. However, long-term complications are reported, mainly weight loss failure and gastroesophageal reflux disease (GERD). Therefore, demand for revisional surgery is rising. OBJECTIVES The aim of this study was to report preliminary results within the 2 main indications for laparoscopic conversion of SG to Roux-en-Y gastric bypass (RYGB). SETTING University Hospital, France. METHODS Data from all patients who underwent laparoscopic conversion from SG to RYGB were retrospectively analyzed as to indications for revisional surgery, weight loss, and complications. RESULTS Forty patients underwent conversion, 29 cases (72.5%) for weight loss failure and 11 cases for refractory GERD (27.5%). The mean interval from SG to RYGB was 32.6 months (range 8-113). Revisional surgery was attempted by laparoscopy in all cases, and conversion to laparotomy was necessary in 3 patients (7.5%). Mean length of follow-up was 18.6 months (range 9-60) after conversion. Follow-up rate was 100%. Mean percent total weight loss and percent excess weight loss were 34.7% and 64%, respectively, when calculated from weight before SG. Remission rate for GERD was 100%. Improvement was observed for all co-morbidities after conversion. There was no immediate postoperative mortality. The postoperative complication rate was 16.7%. According to the Clavien-Dindo classification, there were 5 grade II and 2 grade IIIa complications. CONCLUSION Laparoscopic conversion of SG to RYGB is safe and feasible. In the short term, it appears to be effective in treating GERD and inducing significant additional weight loss and improvement of co-morbidities.

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.

Laparoscopic Conversion of a Sleeve Gastrectomy to the Roux-en-Y Gastric Bypass

After the failure of sleeve gastrectomy (SG), three options are available as a second intervention: the conversion into a biliopancreatic diversion with duodenal switch, the Roux-en-Y gastric bypass (RYGBP), and more recently, a re-SG consisting in the refashioning of a dilated gastric tube. We describe two different approaches for the conversion. The conversion to RYGBP remains a technically challenging operation but feasible and effective, and it should be reserved to specialized centers.

Solitary fibrous tumor of the liver: Report of two cases and review of the literature

A solitary fibrous tumor (SFT) of the liver is a rare neoplasm of mesenchymal origin. 59 cases have been reported in the literature. We report 2 patients who presented with a hepatic solitary fibrous tumor. The first case is a 65-year-old man who presented with an accidental finding of a large mass in the left liver. Biopsy revealed an SFT and left hepatectomy was performed. The diagnosis was confirmed by histopathology. The second case is an 87-year-old woman who presented with disturbances in her liver function tests. A Computed Tomography (CT) scan showed a large mass in the right liver. Surgery was contraindicated because of the patients poor general condition. A biopsy was done and SFT was diagnosed histopathologically. SFT are usually benign but the risk of malignant transformation always exists, which mandates surgical resection as the optimal management of these tumors. However, because of the small sample size and the rarity of the entity, it is difficult to define the evolution, the risk factors and the malignant potential of these tumors.

Predictors of metabolic syndrome persistence 1 year after laparoscopic Roux-en-Y gastric bypass

BACKGROUND Laparoscopic Roux-en-Y gastric bypass (LRYGB) is effective in reversing the metabolic syndrome (MS) in up to 90% of patients. OBJECTIVES The aim of this study was to determine predictors of MS persistence 1 year after LRYGB. SETTING University Hospital, France. METHODS Ninety-one patients with a mean age of 44.4 years and a mean body mass index (BMI) of 43.1 kg/m² meeting the criteria for MS were enrolled in this prospective study. Anthropometric, metabolic, and inflammatory biological parameters were assessed before and 1 year after LRYGB. Patients were divided into 2 groups according to the persistence (MS nonresponders) or resolution of MS (MS responders) 1 year after LRYGB and a comparison was performed at baseline and 1 year after surgery. RESULTS Sixty-nine patients (75.8%) underwent remission, while 22 (24.2%) showed persistence of MS 1 year after LRYGB. At baseline the MS nonresponders group presented significantly higher values of fasting plasma glucose (7.8 versus 5.3 mmol/L, P = .004), glycosylated hemoglobin (HbA1c, 7.3% versus 5.9%, P = .0004), triglycerides (TG, 2.37 versus 1.33 mmol/L, P = .006), and homeostasis model assessment of insulin resistance (HOMA-IR, 442.5 versus 256, P = .006). The rate of diabetes was significantly higher in this group (68.2% versus 36.8%, P = .0086), as well as the number of MS components per patient. One year after LRYGB, the MS nonresponders showed a significantly lower excess BMI lost (EBMIL) (56.1% versus 82.4%, P = .00008). On multivariate analysis, baseline levels of TG, glucose metabolism markers and EBMIL were associated with the persistence of MS. CONCLUSION Baseline levels of TG, plasma fasting glucose, and HbA1c, as well as history of type 2 diabetes and EBMIL, represent predictors of MS persistence 1 year after LRYGB.

Hiatal Hernia, GERD, and Sleeve Gastrectomy: a Complex Interplay

Laparoscopic sleeve gastrectomy (LSG) is considered bymost the ideal bariatric procedure because of its simple and straightforward surgical technique that does not include any digestive anastomosis or intestinal bypass. LSG is also considered as a physiologic procedure because the continuity of the digestive tract is respected. For these reasons, SG is currently the most performed bariatric procedure in many countries [1]. Hiatal hernia (HH) is a frequent condition in the obese patient. Type I HH, defined as the migration of the esophagogastric junction (EGJ) into the chest, is the most common form of HH in obese. Type II is characterized from a localized defect in the phrenoesophageal membrane, while the EGJ remains fixed to the preaortic fascia and the median arcuate ligament. Types III and IV refer to the migration of part of the stomach or other viscera, respectively, into the chest through an enlarged hiatal orifice. The main issue of HH in patients undergoing SG is the association between gastroesophageal reflux disease (GERD) and HH. Indeed, although most bariatric surgeons consider the occurrence of leak at the upper part of the staple line theAchilles’ heel of this procedure, the endeavors of the bariatric community have identified some key factors including the size of the endoluminal bougie, the technique of stapling besides the learning curve that have all contributed to the dramatic reduction in the rate of leak [2, 3]. However, the occurrence of Bde novo GERD^ in previously asymptomatic patients as well as the aggravation after LSG of preexisting reflux symptoms has now emerged as a main concern linked to this procedure. The relationship between GERD and LSG is complex andmultifactorial. The LSG implies the dismantling of some anatomic antireflux mechanisms such as the sling fibers, the His angle, and the partial opening of the hiatal orifice depending on how much the dissection is pushed into the hiatal orifice once the lateral border of the left pillar has been identified. Other factors may be responsible for the occurrence of de novo GERD and/or its aggravation including a stricture of the gastric tube either anatomical or functional, the persistence of part of the gastric fundus, and the caliber of the tube that may determine an increased intraluminal pressure in the gastric tube [4].

General Practitioners and Bariatric Surgery in France: Are They Ready to Face the Challenge?

PurposeThe epidemic of obesity has determined an important rise in popularity for bariatric surgery (BS) in France. The role of general practitioners (GPs) in the decision-making process of candidates to BS as well as in their life-long follow-up after surgery is therefore destined to grow up. The aim of this survey was to provide a picture of the actual knowledge of GPs about BS.MethodsThe link to an e-questionnaire composed of 20 multiple choice questions was sent to all the 101 Departmental Councils of the French Medical Board, accompanied by a letter explaining the objectives of the study. Councils were asked to distribute the e-questionnaire to GPs in their department.ResultsA total of 2224 GPs were solicited by e-mail in six departments and 288 surveys were completed, representing a 12.9% response rate. A proportion as high as 97.2% of GPs reported taking care of at least one patient operated on for BS and 88.5% declared having referred at least one patient for BS. Nevertheless, a considerable proportion of GPs declared not to have sufficient knowledge to manage BS patients. Moreover, 86.1% wished to receive more education and 83.7% declared to be available for participating in follow-up.ConclusionAcademic institutions, scientific societies, and all physicians involved in obesity care should actively participate in the correction of the educational gap of GPs in order to obtain an effective help in the complex challenge of facing the obesity epidemic.

Laparoscopic Duodenal Switch

Duodenal switch (DS) consists of a vertical gastrectomy with duodenal preservation (sleeve gastrectomy [SG]), division of the first portion of the duodenum, and reconnection to the distal 250 cm of ileum. The bypassed duodenum, jejunum, and proximal ileum (biliopancreatic limb) are then reconnected to create a Roux-en-Y anatomy with a common channel of 100 cm and an alimentary channel of 150 cm.