Imed Ben Amor

The inflammatory C-reactive protein is increased in both liver and adipose tissue in severely obese patients independently from metabolic syndrome, Type 2 diabetes, and NASH.

OBJECTIVE:C-Reactive Protein (CRP), a nonspecific marker of inflammation that is moderately elevated in obesity, metabolic syndrome (MS), and type 2 diabetes, has been proposed as a surrogate marker of nonalcoholic steatohepatitis (NASH). Its clinical usefulness in the diagnosis of NASH was evaluated in severely obese patients without or with MS, diabetes, and NASH and the potential roles of the liver and of the adipose tissue in CRP production were characterized.METHODS:Severely obese patients without NASH (without MS [N = 13], with MS [N = 11], or with MS and diabetes [N = 7]) and with NASH (without [N = 8] or with [N = 7] MS) were studied. For each patient, liver and adipose tissue biopsies were collected during a bariatric surgery and were used to determine the CRP gene expression by real-time PCR. The role of interleukin-6 (IL6) and lipopolysaccharide in CRP expression was also evaluated in subcutaneous adipose tissue obtained during cosmetic abdominoplasty.RESULTS:Plasma CRP levels were elevated in severely obese patients independently from the presence or absence of MS, diabetes, or NASH. CRP gene expression was not only increased in livers but also in adipose tissues of obese patients compared with controls subjects. In human adipose tissue, CRP mRNA levels were positively correlated with those of IL-6 and the CRP expression was enhanced in vitro by IL-6 and lipopolysaccharide.CONCLUSION:Plasma CRP levels are not predictive of the diagnosis of NASH in severely obese patients. The liver but also the adipose tissue can produce CRP, a process which could be dependent on IL6. Therefore, both tissues might contribute to the elevated plasma CRP levels found in obesity. In addition, the large amount of body fat may well produce an important part of the circulating CRP, further limiting its clinical usefulness in the evaluation of NASH in severely obese patients.

Trends of bariatric surgery in France during the last 10 years: analysis of 267,466 procedures from 2005–2014

BACKGROUND During the past decade, the field of bariatric surgery has changed dramatically. OBJECTIVES The study aims to summarize and perform a periodic assessment of the current trends in the use of bariatric surgery in France and review findings on the long-term progression of bariatric surgery. The data were extracted from the national registry Programme de Médicalisation des Systèmes d׳Information from 2005 to 2014. SETTING National health system and private practice in France. METHODS We identified all hospitalizations during which a bariatric procedure was performed for the treatment of morbid obesity from 2005 to 2014 in France. Data were reviewed for patient characteristics and the number and types of bariatric procedures. We also analyzed the setting and the characteristics of the centers and the difference of the activity between the public and private sector. RESULTS Between 2005 and 2014, the number of bariatric operations increased fourfold. Sleeve gastrectomy became the most performed bariatric intervention, representing 60.7% of bariatric activity in 2014. There was a concomitant steep increase in sleeve gastrectomy, with Roux-en-Y gastric bypass increasing slightly overall and a substantial decrease in adjustable gastric banding. In 2014, 481 centers performed bariatric surgery. Among them, one third performed<30 operations/yr. We observed an overall in-hospital mortality ranging from .038% to .05% during the last 3 years. CONCLUSION Bariatric surgery is increasing in France, with a fourfold augmentation of interventions in the last 10 years. The number of sleeve gastrectomies has increased considerably. This activity is performed in numerous centers, one third of them performing<30 interventions/yr.

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.

Laparoscopic Entry Techniques in Obese Patient: Veress Needle, Direct Trocar Insertion or Open Entry Technique?

Laparoscopy is a common procedure in bariatric surgery. Serious complications can occur during laparoscopic entry as reported by Ahmad et al. (Cochrane Database Syst Rev 15:2, 2012). Several techniques, instruments, and approaches to minimize the risk of injury (the bowel, bladder, major abdominal vessels, and an anterior abdominal wall vessel) have been introduced. These methods include the standard technique of insufflation after insertion of the Veress needle, the open (Hasson technique), the direct trocar insertion, and optical trocar insertion. Furthermore, it is more difficult to perform in the obese patient, especially if the first trocar is not umbilical. This is because obese patients have a very thick abdominal wall (particularly in women) as well as a thick peritoneum. The aim of this article was to demonstrate the safety of various laparoscopic entry techniques in obese patient.

Complications of bariatric surgery: Presentation and emergency management

The epidemic in obesity has led to an increase in number of so called bariatric procedures. Doctors are less comfortable managing an obese patient after bariatric surgery. Peri-operative mortality is less than 1%. The specific feature in the obese patient is that the classical signs of peritoneal irritation are never present as there is no abdominal wall and therefore no guarding or rigidity. Simple post-operative tachycardia in obese patients should be taken seriously as it is a WARNING SIGNAL. The most common complication after surgery is peritonitis due to anastomotic fistula formation. This occurs typically as an early complication within the first 10 days post-operatively and has an incidence of 1-6% after gastric bypass and 3-7% after sleeve gastrectomy. Post-operative malnutrition is extremely rare after restrictive surgery (ring, sleeve gastrectomy) although may occur after malabsorbative surgery (bypass, biliary pancreatic shunt) and is due to the restriction and change in absorption. Prophylactic cholecystectomy is not routinely carried out during the same procedure as the bypass. Superior mesenteric vein thrombosis after bariatric surgery is a diagnosis which should be considered in the presence of any postoperative abdominal pain. Initially a first etiological assessment is performed (measurement of antithrombin III and of protein C and protein S, testing for activated protein C resistance). If the least doubt is present, a medical or surgical consultation should be requested with a specialist practitioner in the management of obese patients as death rates increase with delayed diagnosis.

Increased Prevalence of Irritable Bowel Syndrome in a Cohort of French Morbidly Obese Patients Candidate for Bariatric Surgery

BackgroundOnly a few recent reports have suggested a correlation between obesity and irritable bowel syndrome (IBS). We aimed to determine the prevalence and severity of IBS in a prospective cohort of obese patients undergoing bariatric surgery in Nice Hospital (France).MethodsOne hundred obese patients were included prospectively before bariatric surgery. A diagnosis of IBS and each subtype was performed according to Rome-III criteria using a Bristol scale for stool consistency. Patients provided information on IBS-related comorbidities, including chronic fatigue, migraine, lower back pain, gastroesophageal reflux disease (GERD), genitourinary problems, and dyspepsia. Patients completed questionnaires to assess the severity of IBS, GERD, psychological factors (anxiety, depression), fatigue, and quality of life.ResultsThirty patients fulfilled the Rome-III criteria for IBS. There was no difference in age, gender, or BMI between obese patients with or without IBS. Obese patients with IBS reported a significantly higher prevalence of GERD, migraines, lower back pain, genitourinary problems, chronic fatigue, and dyspepsia. Obese patients with IBS had significant higher scores of fatigue, anxiety, depression, and poorer quality of life. Obese patients that had both IBS and GERD had significantly higher IBS severity scores than those without GERD. In a logistic regression model including BMI, anxiety, depression, gender, and GERD score, only anxiety was significantly and independently associated with IBS.ConclusionsThirty percent of obese patients had IBS: its severity was not correlated with BMI. However, anxiety was independently associated with IBS, suggesting that psychological factors are key features of IBS, whatever the presence of obesity.

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.

Division of the stomach and checking haemostasis for performing sleeve gastrectomy. Points of controversy.

Teams vary as to their choice of type of gastroplasty tube: either the ring, the MIDSLEEVE (MID, Medical Innovation Development, France) developed for this type of surgery, or a reusable Faucher tube. Although the volume of the 25-cm tube is the same as a 32 or 40Fr bougie, a narrower tube achieves better weight loss [2]. For this reason, the 2011 consensus conference agreed on the use of a tube of between 32 and 36Fr diameter. Another point of controversy is the thickness of the staples. The consensus conference recommended staples over 2.5 mm deep for first line surgery and staples of at least 4.8 mm deep for revision surgery (when the tissues are thicker). It is recognised that the wall of the antrum is thicker than that of the rest of the stomach and increases in thickness with increasing BMI [3]. Despite this, teams vary greatly as to the type of staples they use: 4.8 (green) for the antrum then 3.5 (blue) for the rest of the stomach, or conversely 3.5 for the antrum and 4.8 for the stomach, or 3.8 mm (gold) for the entire stomach or 3.5 (blue) for all the stapling, or alternatively violet charges (33.5-4) for the whole stomach [4]. There are no comparative studies between the type of clamp and the staple charge used, nor are there any comparative studies about preoperative event rates (stapling failure) or postoperative complications (fistulae or bleeding). Some surgeons routinely add a ligature around the stapling line overlap. Another point of debate is how to perform the stapling: either very tightly onto the tube or simply in contact without applying tension to the tissue (causing less ischaemia?). Finally, the question of possibly reinforcing the stapling to reduce the risk of fistulae remains open. The incidence of fistulae is between 0 and 5 % for initial surgery and doubles for revision surgery [5]. No studies have yet provided a conclusion on the impact of reinforcement on fistulae rates. As the incidence of fistulae is low, a series of over 10,000 procedures would be needed in order to obtain statistically valid data [6]. Different options have been proposed to try to reduce the risk of fistulae, including sutures, biological glues and strengthening the stapling. Although glues have not been proved to be effective, a few studies have described reduced fistulae rates [7]. When the stapling line is oversewn, the technique used also varies between groups: the oversewing may either roll over the stapling line, although in this case, a wider tube is needed to have sufficient gastric tissue (“plicatured sleeve”!) or the oversewing follows the stapling line (a procedure causing ischaemia?) [8]. In addition, the size and type of needle and suture material used also varies R. Kassir (*) Department of Bariatric Surgery, CHU Hospital, Jean Monnet University, Avenue Albert Raimond, 42270 Saint Etienne, France e-mail: radwankassir42@hotmail.fr

Postoperative Mortality After Bariatric Surgery: Do the Numbers Reflect the Reality?

Obesity has emerged as a major public health problem worldwide in the last decade. Surgery has proven to be the only effective sustained weight loss option for many patients. The number of bariatric procedures has substantially increased every year in the last decade. In France, 47,084 patients underwent a bariatric intervention in 2014, which represents almost the quadruple of interventions done in 2005 [1]. The postoperative mortality rate in bariatric surgery has significantly decreased during the last decade. Recent data from the United States National Inpatient Sample has shown that in-hospital mortality has dropped from 0.8 % in 1998 to 0.07 % in 2012 [2]. We recently reported that in-hospital mortality after bariatric surgery in France was as low as 0.038% in 2014 [1]. There are several reasons for the decrease in the mortality rate. First, the volume of surgery has increased substantially during the past decade, and volume has been shown to be a major predictor of outcome. In a study examining the relationship between hospital volume and outcomes in bariatric surgery, Nguyen and colleagues reported that the observed mortality was considerably lower at high-volume compared with low-volume hospitals (0.3 vs 1.2 %, respectively) [2]. Second, innovations in bariatric surgical techniques lead to better preparation and selection of patients. Lastly, the quality and efficacy of the staplers and the vessel sealing devices have substantially improved [3]. National registry and international societies have been created in the effort to collect, publish, and compare bariatric surgery data, including postoperative mortality. Analyzing the results of postoperative mortality, several problems emerge. First of all, the definition of postoperative mortality is not homogeneous: some authors report inhospital mortality [1] whereas others report 30-day mortality [4], and others 90-day mortality [5]. It is clear that we cannot compare results if definitions are so different. Second, fast-track and enhanced recovery is substantially spreading in the field of bariatric surgery, leading to shorter hospitalization periods and even to the introduction of ambulatory bariatric procedures. Consequently, mortality during hospitalization is less frequent, and it may be difficult to detect all postoperative deaths. Readmission may be coded differently, and the eventual postoperative death may escape the count. Third, the centralization of bariatric procedures may lead low-volume centers to transfer patients who develop serious complications to high-volume referral centers. As a result, all these factors may lead to underestimate the results of postoperative mortality. * Tarek Debs dr.debs@hotmail.com