Jérémie Thereaux

Gastric Band Removal in Revisional Bariatric Surgery, One-Step Versus Two-Step: a Systematic Review and Meta-analysis

We aimed to systematically review the literature comparing the safety of one-step versus two-step revisional bariatric surgery from laparoscopic adjustable gastric banding (LAGB) to Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). There is debate on the safety of removing the gastric band and performing revisional surgery immediately or in a delayed, two-step fashion due to potential higher complications in one-step revisions. A systematic and comprehensive search of the literature was conducted. Included studies directly compared one-step and two-step revisional surgery. Eleven studies were included with 1370 patients. Meta-analysis found comparable rates of complications, morbidity, and mortality between one-step and two-step revisions for both RYGB and SG groups. This suggests that immediate or delayed revisional bariatric surgeries are both safe options for LAGB revisions.

Laparoscopic sleeve gastrectomy versus laparoscopic mini gastric bypass: One year outcomes

PURPOSEnSleeve gastrectomy (LSG) and mini gastric bypass (LMGB) was considered as emerging procedures but are now considered for many authors as an alternative of the Roux-Y gastric bypass because of similar percentages of weight loss and better postoperative morbidity profiles. However, studies comparing LSG and LMGB are scarce.nnnMATERIALS AND METHODSnFrom January 2010 to July 2014, 262 and 161 patients underwent LSG or LMGB in two centre of bariatric surgery, respectively. At one year, rate of follow-up was 88.4%. Main outcome was % of Total Weight Loss (%TWL) at one year. Propensity score matching and multivariable analyses were used to compensate for differences in some baseline characteristics.nnnRESULTSnAfter matching LSG (Nxa0=xa0136) and LMGB (Nxa0=xa0136) groups did not differ for initial BMI (kg/m(2)) (43.4xa0±xa06.5 vs. 42.8xa0±xa05.0; Pxa0=xa00.34), % of female patients (91.9% vs. 93.4%; Pxa0=xa00.64), age (years) (41.2xa0±xa012.3 vs. 41.2xa0±xa011.3; Pxa0=xa00.99) and diabetes (15.4% vs. 19.9%; Pxa0=xa00.34). At one year, %TWL, change in BMI and rate of stenosis were higher for LMGB group, respectively: 38.2xa0±xa08.4 vs. 34.3xa0±xa08.4 (Pxa0<xa00.0001);xa0-16.5xa0±xa04.6 vs.xa0-14.9xa0±xa04.4 (Pxa0=xa00.005) and 16.9% vs. 0% (Pxa0<xa00.0001). In multivariate analyses (β coefficient), LMGB was a positive independent factor of %TWL (2.8; Pxa0=xa00.008).nnnCONCLUSIONnLMGB seems to have better weight loss at one year compared to LSG with higher gastric complications. Further long term studies are needed.

Colovesical Fistula Complicating Diverticular Disease: A 14-Year Experience.

Objective: Colovesical fistulas (CVF) constitute the most common type of spontaneously occurring fistulas associated with diverticular disease. One-stage laparoscopic resection has been shown to be feasible, but studies comparing this approach to open surgery are scarce. The aim of this study was to compare the clinical outcomes of open and laparoscopic surgery for CVF of diverticular origin. Materials and Methods: From January 2000 to July 2014, 37 colectomies were performed for diverticular disease–related CVF. Twenty-eight patients who underwent resection and primary anastomosis were divided in 2 groups: the laparoscopic surgery group (group A) and the open surgery group (group B). We have analyzed the following parameters: operative time, complication rate, hospital stay, recurrence, and early mortality rate. Results: Groups A and B were comparable in terms of age, sex, diverticulitis episodes, previous abdominal surgery, and body mass index. The mean duration of surgery was significantly shorter in group B: 175 versus 237 minutes (P=0.011). There was a faster recovery of gastrointestinal transit in group A (2 vs. 13; P=0, 0002). However, there were no significant differences between the groups with respect to serious postoperative morbidity [(Clavien-Dindo scores of 3, 4, and 5) 4 vs. 0; P=0.098)] and with respect to hospital stay (10.5 vs. 9.5 d; P=0.537). There was no recurrence during a median follow-up of 12 months. Conclusions: Laparoscopic resection and primary anastomosis should be considered a safe and feasible option for the management of diverticular CVF. Despite progresses in minimally invasive colorectal surgery, the conversion rate and morbidity are still high.

Primary Closure Versus Biliary Drainage After Laparoscopic Choledocotomy: Results of a Comparative Study.

Introduction: To evaluate the feasibility, safety, and short-term outcomes of primary closure (PC) and biliary drainage (BD), after the laparoscopic treatment of common bile duct (CBD) stones by choledocotomy. Patients and Methods: Between January 2009 and December 2014, 102 patients underwent laparoscopy for lithiasis of the CBD. Intraoperative cholangiography was systematically performed, followed by choledocoscopy, depending on the size of the CBD. Results: Eighty (78.4%) of the 102 patients underwent laparoscopic stone extraction by choledocotomy, and were assigned to 2 groups: PC (group A, n=25), and BD (group B, n=55). Groups A and B were comparable in terms of age (62.3±26.1 vs. 66.0±19.3 y; P=0.53), the percentage of women (72.0% vs. 76.4%; P=0.68), body mass index (25.9±6.1 vs. 26.9±4.4 kg/m2; P=0.52), and CBD diameter (11.6±3.1 vs. 12.1±3.8 mm; P=0.59). The mean durations of surgery and of hospital stay were significantly shorter in group A: 179±38 versus 211±57 minutes (P=0.02) and 5.4±2.0 versus 8.4±3.2 days (P<0.001). Groups A and B were comparable in terms of serious postoperative morbidity (Clavien-Dindo scores of 3, 4, and 5): 2 versus 4 (P=1). In group B, bile drain removal was complicated by choleperitoneum in 3 cases. Conclusions: With shorter durations of surgery and hospital stay, equivalent postoperative morbi-mortality, and an absence of the specific morbidity due to bile drainage, PC may be considered a safe and feasible option for the laparoscopic management of CBD stones by choledocotomy.

Laparoscopic Conversion of Sleeve Gastrectomy to Gastric Bypass for Super-Obesity (BMI ≥ 50 kg/m²) and Incisional Hernia: a Video Report.

BackgroundLaparoscopic sleeve gastrectomy (LSG) is the most frequently performed procedure for morbid obesity in France. However, in case of de novo gastroesophageal reflux disease or of insufficient weight loss, LSG could be converted in rare cases to laparoscopic Roux-en-Y gastric bypass (LRYGB). In case of voluminous incisional hernia (IH) associated, this procedure could be technically challenging, especially in cases of super-obesity (body mass index (BMI) ≥50xa0kg/m2). Furthermore, IH should be repaired in order to avoid life-threatening post-operative small bowel obstruction.MethodsWe present the case of a 30-year-old woman (125xa0kg, 1.55xa0m) with a BMI of 52.1xa0kg/m2. She was referred to our tertiary care center for weight regain (Nadir 100xa0kg), 4xa0years after a LSG was performed for super-super obesity (BMIu2009=u200968.7xa0kg/m2). She also had a history of epigastric IH (single-incision LSG; diameteru2009=u200910xa0cm). The strategy adopted was to repair hernia with raphy. In case of hernia recurrence and of sustainable weight loss, use of prothetic mesh would be mandatory in the future.ResultsIn this multimedia video, we present a step-by-step laparoscopic conversion of sleeve gastrectomy to LRYGB for super-obesity (BMI ≥50xa0kg/m2) and incisional hernia. Laparoscopic procedure included adhesiolysis, dissection, and resection of the low part of the remnant stomach, gastro-jejunal circular anastomosis, and closure of aponeurosis defect.ConclusionsIncisional hernia and morbid obesity are often entangled problems. Revisional procedure of bariatric surgery with incisional hernia associated should be performed laparoscopically.

Laparoscopic Revision of Gastric Bypass for Gastrojejunal Anastomotic Stenosis and Trans-mesocolic Defect: Video Report

PurposeLaparoscopic gastric bypass (LRYGB) is considered as the gold standard procedure for morbid obesity because of sustainable weight loss and coexisting conditions improvements (Sjostrom L et al. The New England journal of medicine 351(26):2683-93, 2004 [1]; Thereaux J et al. Surg Obesity Related Dis: Off J Am Soc Bariatric Surg, 2014 [2]). However, there are some concerns with the late risk of gastrojejunal anastomotic stenosis and of small bowel obstruction (Hamdan K et al. 98(10):1345-55, 2011 [3]).Materials and MethodsWe present the case of a 46-year-old woman (70xa0kg, 1.67xa0m) with a body mass index (BMI) of 25.1xa0kg/m2 who had undergone LRYGB, 3xa0years ago (initial BMI 45xa0kg/m2). She was referred to our tertiary care center for dysphagia and abdominal pain.ResultsIn this multimedia video, we present a step-by-step laparoscopic revision of a LRYGB for gastrojejunal anastomotic stenosis associated with trans-mesocolic defect. Procedure included dissection and resection of the strictured anastomosis, redo gastrojejunal circular anastomosis, and closure of the trans-mesocolic defect. No adverse outcomes occurred during the postoperative period.ConclusionGastrojejunal anastomosis stenosis should be managed under laparoscopy. All abdominal surgery in patients with a history of LRYGB, especially with trans-mesocolic alimentary limb, should include inspection of potential meso-defect.

Long-term functional and oncological results after sphincter-saving resection for rectal cancer - Cohort study

PURPOSEnThe treatment of rectal cancer could be complex and the long term complications have the potential to greatly impact the quality of life. The aim of this study was to evaluate the long term functional and oncological results after sphincter-saving resection for rectal cancer.nnnMETHODSnBetween January 2005 and December 2013, a total of 187 rectal resections with total mesorectal excision (TME) for cancer were performed. The data of 72 (38.5%) patients were available for analysis. Long-term follow-up was used to analyze the oncologic and functional results. Standardized questionnaires were used to determine fecal incontinence and urinary function. Relevant clinical variables were evaluated using univariate and multivariate analyses.nnnRESULTSnThe overall survival rate was 71% and the distribution of the International Union against Cancer (UICC) stages was 48.6% stage 1, 18% stage 2, and 33.3% stage 3. In univariate analysis, neoadjuvant radiotherapy (Pu202f<u202f0.01), rectal pouch (Pu202f<u202f0.01) and hand-sewn anastomosis (Pu202f=u202f0.02) was found to adversely affect fecal continence. On multivariate analysis fecal incontinence was significantly correlated with neoadjuvant radiochemotherapy (Pu202f<u202f0.05) and low rectal resection (Pu202f<u202f0.01). Urinary function was not statistically significant affected by preoperative treatment (Pu202f=u202f0.48) or surgical procedure (Pu202f=u202f0.45).nnnCONCLUSIONnTumor location, surgical technique and neoadjuvant treatment had an impact on long term oncologic and functional results after sphincter-saving resection for rectal cancer. Urinary dysfunction occurs less frequently than anal disorders. These results highlight the importance of functional evaluation before and after rectal cancer resection in daily clinical practice and the necessity to tailor treatment to each patient.

Surgical and oncological long term outcomes of gastrointestinal stromal tumors (GIST) resection- retrospective cohort study

PURPOSEnSurgery remains the mainstay of gastrointestinal stromal tumors (GISTs) treatment. The aim of our study was to compare postoperative outcomes and long term oncologic results of GISTs resection. An analysis of laparoscopic versus open surgery for GISTs and a subgroup analysis of lesions larger than 5u202fcm were realized.nnnMATERIALS AND METHODSnBetween January 2005 and December 2014, 143 patients with primary GISTs were treated with radical resection in two tertiary centers. Eight patients with metastatic disease were excluded. The remaining patients were assigned to 2 groups: laparoscopy and open surgery. A separate analysis of tumors larger than 5u202fcm was realized for the laparoscopy group. Long-term follow-up was used to analyze the oncologic and surgical results. Relevant clinical variables were evaluated using univariate and multivariate analyses.nnnRESULTSnWith similar oncological outcomes(pu202f=u202f0.09) and morbidity(pu202f=u202f0.56), laparoscopy compared to open surgery significantly reduced length of hospitalization (pu202f=u202f0.01). For lesions >5u202fcm laparoscopic resection is associated with similar short-term outcomes with resection for small tumors without compromising oncological outcomes (pu202f=u202f0.89). For all patients, the probability of remaining disease free at 3 years, and 5 years was 97, 6% and 95%, respectively.nnnCONCLUSIONnLaparoscopic resection is a technically and oncologically safe and feasible approach for GISTs compared with open resection. Resection of lesions superior of 5u202fcm by laparoscopy has efficacy and recurrence rates similar to open surgical controls. Large tumor resection should only be attempted by surgeons with a large experience with minimally invasive surgery in order to avoid operative complications and unfavorable long term outcome.

Conversion of Vertical Banded Gastroplasty to Laparoscopic Gastric Bypass: a Step-By-Step Teaching Video

PurposeVertical banded gastroplasty (VBG) has been demonstrated to be disappointing for long-term weight loss and quality of life (Br J Surg 100:222–230, 2013). Laparoscopic revisional gastric bypass has been found to be feasible, but this procedure in case of prior VBG is deemed both challenging and difficult and should be performed by experienced surgeons (Obes Surg 22:1554–1561, 2012; Surg Endosc 27:558–564, 2013).Materials and MethodsWe present the case of a 56-year-old man with a body mass index (BMI) of 39.6xa0kg/m2 who had undergone open VBG, 11xa0years ago (initial BMI 39.2xa0kg/m2). He was referred to our tertiary care center for weight regain and daily vomiting.ResultsIn this high definition multimedia video, we present a step-by-step laparoscopic conversion of VBG to gastric bypass. After careful adhesiolysis, key points of such procedure are resizing of the small gastric pouch and resection of the enlarged gastric pouch with the band and the upper portion of the remnant fundus, in order to avoid leakage or blind stomach pouch. No adverse outcomes occurred during the postoperative period.ConclusionLaparoscopic conversion of previous open VBG to gastric bypass is a challenging procedure. Learning the key points of such procedure is mandatory to limit postoperative complications.

Conversion of Nissen fundoplication to laparoscopic gastric bypass: video case report and literature review.

/10.10 15 A ence: etabo uy-Pr ie.th Gastroesophageal reflux disease (GERD) is a common disease, especially in developed countries, with a prevalence of 415% in the United States [1]. Its risk increases progressively with increasing weight [2]. Hence, GERD can develop as an obesity-related co-morbidity and is one of the main factors leading to bariatric surgery in obese patients, with a preoperative rate of around 30% [3,4]. However, before the routine use of bariatric surgery, fundoplication was considered the treatment of choice for GERD showing dependence on or resistance to proton pump inhibitors. Laparoscopic Roux-en-Y gastric bypass (LRYGB) has become the procedure of choice because of its high success rate for the treatment of GERD [5]. Furthermore, sleeve gastrectomy may actually worsen the symptoms of GERD and is not recommended for some patients [6]. However, LRYGB for morbidly obese patients is a technically challenging procedure, especially in those who have undergone hiatal surgery [6,7–12]. Here, we report the case of a woman who underwent laparoscopy to convert a Nissen fundoplication to LRYGB.