Gilles Chassot

Reducing cost of surgery by avoiding complications: the model of robotic Roux-en-Y gastric bypass.

BackgroundRobotic surgery is a complex technology offering technical advantages over conventional methods. Still, clinical outcomes and financial issues have been subjects of debate. Several studies have demonstrated higher costs for robotic surgery when compared to laparoscopy or open surgery. However, other studies showed fewer costly anastomotic complications after robotic Roux-en-Y gastric bypass (RYGBP) when compared to laparoscopy.MethodsWe collected data for our gastric bypass patients who underwent open, laparoscopic, or robotic surgery from June 1997 to July 2010. Demographic data, BMI, complications, mortality, intensive care unit stay, hospitalization, and operating room (OR) costs were analyzed and a cost projection completed. Sensitivity analyses were performed for varied leak rates during laparoscopy, number of robotic cases per month, number of additional staplers during robotic surgery, and varied OR times for robotic cases.ResultsNine-hundred ninety patients underwent gastric bypass surgery at the University Hospital Geneva from June 1997 to July 2010. There were 524 open, 323 laparoscopic, and 143 robotic cases. Significantly fewer anastomotic complications occurred after open and robotic RYGBP when compared to laparoscopy. OR material costs were slightly less for robotic surgery (USD 5,427) than for laparoscopy (USD 5,494), but more than for the open procedure (USD 2,251). Overall, robotic gastric bypass (USD 19,363) was cheaper when compared to laparoscopy (USD 21,697) and open surgery (USD 23,000).ConclusionsRobotic RYGBP can be cost effective due to balancing greater robotic overhead costs with the savings associated with avoiding stapler use and costly anastomotic complications.

Factors influencing energy intake and body weight loss after gastric bypass.

Objective: The gastric bypass-induced quantitative and qualitative modifications of energy intake (En In, kcal/day) and their impact on body weight (bw) loss were evaluated. The factors influencing energy intake and body weight loss were also investigated.Design: Longitudinal study.Setting: University Hospital of Geneva.Subjects: Fifty obese women undergoing a Roux-en-Y gastric bypass.Results: The reduction of EnIn was significantly related to bw loss expressed either in kg or as percentage correction of excess bw (P<0.01 for both), whereas the post-operative modifications of diet composition did not play a role. Age and initial bw significantly influenced bw loss (P<0.0001 and P<0.001, respectively), as shown by multiple regression analysis. Patients were divided into four sub-groups according to their age (under or over 35 y) and initial bw (under or over 120 kg). ANOVA showed that under 35-y-old subjects reduced their EnIn significantly more than their older counterparts having similar bw (P<0.02 and P<0.05); consequently, bw loss, expressed in kg, was significantly (P<0.0001 and P<0.0005) larger in younger patients. Subjects with an initial bw over 120 kg lost significantly (P<0.001 and P<0.02) more weight as compared to patients with a smaller degree of obesity (under 120 kg) and similar age.Conclusions: Gastric bypass-induced body weight loss is mainly due to the reduction of EnIn, whereas the qualitative modifications of the diet do not play a role. Younger subjects have a greater capacity to reduce EnIn and, therefore, lose more weight. Pre-operative high degree of obesity leads to a larger weight reduction, probably because of a greater energy deficit.

The role of revascularization in celiac occlusion and pancreatoduodenectomy.

BACKGROUND Performance of pancreatoduodenectomy involves sacrifice of the gastroduodenal artery (GDA), which poses an ischemic threat to the liver, stomach, pancreas, and various anastomoses in patients with celiac trunk occlusion. METHODS A survey was conducted in surgical centers with expertise in the field of pancreatic surgery. Detailed information was collected from 17 institutions worldwide. Fifteen patients with celiac trunk obstruction were identified. The indication for resection was periampullary tumor in 10 cases and chronic pancreatitis in 5. RESULTS The cause of occlusion was atheromatous disease in 13 cases and arcuate ligament in 2. Trial clamping of the GDA was done in 11 patients, and provoked obvious ischemia in 4. Six patients underwent vascular procedures: the arcuate ligament was severed in 2 cases, the GDA was preserved in 2 cases of chronic pancreatitis, an aorto-hepatic bypass was performed in 1 case, and the celiac trunk was reimplanted in 1 case. Complications occurred in 5 patients, with 2 fatalities. CONCLUSIONS Occlusion of the celiac trunk in patients undergoing pancreatoduodenectomy rarely leads to significant problems. Trial clamping of the GDA is required to assess the need for revascularization.

Preoperative work-up in asymptomatic patients undergoing Roux-en-Y gastric bypass: is endoscopy mandatory?

Background: We aimed to determine before Roux-en-Y gastric bypass (RYGBP) in asymptomatic morbidly obese patients: 1) the prevalence of abnormal findings at upper gastrointestinal (UGI) endoscopy; 2) Helicobacter pylori (HP) status; 3) clinical consequences of these findings; and 4) associated costs. Methods: We retrospectively reviewed 468 consecutive patients, excluded those with UGI symptoms, drug intake or previous UGI endoscopy/surgery, and analyzed findings in the 319 remaining patients (68%). Results: There were abnormal findings in 147 patients (46%), including 54 hiatal hernias and 146 parietal (i.e. mucosal or submucosal) lesions. The most significant were 7 ulcers and 2 gastric polyposis. HP was detected (using CLO-test) in 124 patients (39%). Histopathological examination of biopsies was abnormal in 109/161 patients (68%), and disclosed mainly chronic gastritis (n=98). Abnormal findings were more frequent in HP-positive compared to HP-negative patients (94 vs 51%, P<0.001). Findings had clinical implications in only 4% of patients: delayed surgery (7 ulcers), prophylactic gastrectomy (2 gastric polyposis), unnecessary work-up (3 irrelevant/false-positive diagnoses), and inclusion in a screening program (1 Barretts esophagus). Mean cost of complete UGI work-up was 389 €/patient. Conclusion: Asymptomatic morbidly obese patients frequently harbour UGI lesions warranting UGI work-up before RYGBP. However, routine endoscopy presents drawbacks. We propose a less invasive strategy which reduces costs and limits false-positive results and the subsequent investigations that they require. In our series, it would have missed two gastric polyposis only, for which no formal recommendation has yet been issued. This strategy could be a valuable alternative to routine UGI endoscopy before RYGBP in asymptomatic patients.

Surgical management of abdominal and retroperitoneal Castleman's disease

BackgroundAbdominal and retroperitoneal Castlemans disease could present either as a localized disease or as a systemic disease. Castlemans disease is a lymphoid hyperplasia related to human Herpes virus type 8, which could have an aggressive behavior, similar to that of malignant lymphoid neoplasm mainly with the systemic type, or a benign one in its localized form.MethodsThe authors report two cases of localized Castlemans disease in the retroperitoneal space and review the current and recent progress in the knowledge of this atypical disease.Cases presentationThe two patients were young healthy women presenting with a hyper vascular peri-renal mass suggestive of malignant tumor. Both have been resected in-toto. One of them had an extensive resection with nephrectomy, while the second had a kidney preserving surgery. Pathological examination revealed localized Castlemans disease and surgical margins were free of disease. Postoperative course was uneventful, and after more than 5-years of follow-up no recurrences have been observed.ConclusionLocalized Castlemans disease should be considered when facing a solid hypervascular abdominal or retroperitoneal mass. A better knowledge of this disorder and its characteristic would help surgeon to avoid unnecessarily extensive resection for this benign disorder when dealing with abdominal or retroperitoneal tumors. Surgical resection is curative for the localized form, when complete, while splenectomy could be indicated for the systemic form.

Robotic revisional bariatric surgery: a comparative study with laparoscopic and open surgery.

Revisional bariatric procedures (RBP) can be technically challenging. While robotics might provide help for complex procedures, the study aim was to report our experience with robotic RBP.

Independent Evolution of Heart Autonomic Function and Insulin Sensitivity During Weight Loss

In order to investigate the improvement of insulin resistance and cardiac autonomic function along massive weight loss, 12 obese women were evaluated before, and 3 and 12 months after Roux‐en‐Y gastric bypass. The 12‐month values were compared to those of BMI‐matched controls. Insulin sensitivity was assessed by euglycemic clamp and the cardiac autonomic function by the analysis of the Heart Rate Variability (HRV). After surgery, glucose uptake progressively increased from 4.3 ± 0.5 mg/kg lean body mass (LBM)/min preoperative (pre‐op) to 4.9 ± 0.5 and 7.0 ± 0.5, 3‐ and 12‐month postoperative (post‐op) (P = 0.04 and P = 0.006 vs. pre‐op), whereas the cardiac autonomic function showed a biphasic pattern. HRV values increased 3 months post‐op, and decreased at 12 months, thus indicating an early sympathetic withdrawal followed by a later reactivation (e.g., the standard deviation of the normal‐to‐normal intervals was 116 ± 7 ms in pre‐op, 161 ± 10 at 3 months, P = 0.008 vs. pre‐op, and 146 ± 15 at 12 months, P = 0.03 vs. pre‐op and P = 0.02 vs. 3 m). Insulin sensitivity was significantly related to body weight (P = 0.02), whereas the cardiac indexes were significantly linked to the profile of energy intake (e.g., HRV triangular index vs. energy intake P = 0.003). No significant relationship linked insulin sensitivity to the cardiac autonomic indexes. Insulin sensitivity and cardiac parameters of the 12‐month post‐op patients were similar to their matched controls. During massive weight loss, the cardiac autonomic deregulation and insulin resistance improved concomitantly but independently from each other. Our results suggest that the extent of the improvement is associated with the final body weight.

The effect of insulin on cardiac autonomic balance predicts weight reduction after gastric bypass.

Aims/hypothesisThe aim of this study was to assess the predictive role of autonomic reactivity in body weight loss induced by gastric bypass.MethodsA group of 22 morbidly obese subjects, who were due to undergo a gastric bypass, were submitted, before surgery, to a euglycaemic–hyperinsulinaemic clamp, during which a continuous recording of the ECG was performed. The effect of insulin on cardiac autonomic balance was evaluated by performing power spectral analysis of heart rate variability. The low-to-high frequency ratio was calculated before and during the clamp and its modifications were expressed as % delta low-to-high frequency ratio (%Δ L: H).ResultsPreoperative %Δ L: H showed a significant (p=0.0009, r2=0.43), positive relationship to the reduction of body weight, measured 1 year after surgery and expressed as % excess weight loss (% EWL). Preoperative BMI was also significantly (p=0.0009, r2=0.43) negatively related to the 12-month % EWL. In a multiple regression analysis, %Δ L: H remained a significant (p=0.003), independent predictor of body weight loss, even when preoperative BMI or age, % fat mass, insulinaemia and glucose disposal were taken into account.Conclusions/interpretationThe best correction of excess body weight was achieved by those obese subjects who had a preserved capacity to shift their cardiac autonomic balance towards a sympathetic prevalence in response to an euglycaemic–hyperinsulinaemic clamp. Further studies are needed to elucidate the mechanisms through which the autonomic nervous system influences weight reduction.

Roux‐en‐Y gastric bypass for super obese patients: what approach?

Super obese (SO) patients with a Body Mass Index (BMI) ≥ 50 kg/m2 still represent a real anesthesiological and surgical challenge. While the best procedure to perform in this population remains unclear, robotic technology has been proposed to accomplish Roux‐en‐Y gastric bypass (RYGB). The study aim is to report our experience of robotic RYGB for SO patients and to compare it with open and laparoscopic surgery.