Lionel Rebibo

Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization).

BACKGROUND Day-case surgery (DCS) has boomed over recent years, as has laparoscopic sleeve gastrectomy (SG) for the treatment of morbid obesity. The objective of this study was to evaluate the safety and feasibility of day-case SG. METHODS This was a prospective, nonrandomized study of 100 patients undergoing day-case SG from May 2011 to July 2013. All patients met the criteria for DCS and for the treatment of morbid obesity. Standard surgical, anesthetic, and analgesic protocols were used. The primary study endpoint was the unplanned overnight admission rate. Secondary endpoints were standard DCS criteria, frequency and type of complications, and satisfaction rate of performing day-case SG. The short-term postoperative course of patients undergoing day-case and conventional SG also were compared. RESULTS A total of 416 patients were screened and 100 (24%) were included. There were 8 unplanned overnight admissions. Seven unexpected consultations, 7 hospital readmissions, and 5 major complications were recorded, including 3 cases of unexpected surgery for gastric leak. At follow-up, 96% of the patients were satisfied with day-case SG. The short-term postoperative course was similar among patients undergoing DCS and conventional management. CONCLUSION In selected patients, day-case SG is feasible with acceptable complication and readmission rates. The postoperative course was similar to that observed for standard SG.

Two lessons from a 5-year follow-up study of laparoscopic sleeve gastrectomy: Persistent, relevant weight loss and a short surgical learning curve

INTRODUCTION Like Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy (LSG) has been validated as a bariatric surgery procedure in its own right. However, the few studies of the long-term outcomes of LSG have only featured small patient populations. The objective of the present study was to evaluate weight loss 5 years after LSG and assess the surgical learning curve for this procedure. METHODS We performed a retrospective, single-center study of a prospective database including all consecutive patients having undergone LSG at Amiens University Medical Center between November 2004 and July 2007. Data (weight, body mass index [BMI], percentage of excess weight loss [EWL], percentage of excess BMI loss, and percentage weight loss [PWL]) were collected during follow-up (particularly after 5 years). RESULTS The study population comprised 118 patients (100 females [85%]; mean ± SD age, 40 ± 11 years; mean preoperative weight, 131 ± 22 kg; mean preoperative BMI, 47.7 ± 7 kg/m(2)). LSG was performed after failure of gastric banding in 23 cases (19%) and after failure of an intragastric balloon in 1 (0.8%). In all, 95 patients (81%) were analyzed ≥60 months after the LSG (mean follow-up period, 71 ± 9 months). The PWL and EWL were 25 ± 14% and 46 ± 26%, respectively. Eleven patients had undergone a second bariatric operation within 5 years of the LSG. Concerning the 84 patients in whom only LSG was the only operation, the PWL and EWL were 23 ± 14% and 43 ± 25%, respectively. The EWL was >50% in 35 of these 84 patients (42%) and between 25 and 50% in 30 cases (36%). Optimal weight results were achieved after only 28 LSG had been performed, which testifies to a shorter learning curve than for most other bariatric surgery techniques. CONCLUSION Isolated LSG is a quickly mastered bariatric surgery technique with a short learning curve. It enables a mean PWL of >25% and an EWL of >50% in >40% of cases.

Management of gastrobronchial fistula after laparoscopic sleeve gastrectomy

BACKGROUND Gastric fistula (GF) is a serious complication after laparoscopic sleeve gastrectomy (LSG). Furthermore, gastrobronchial fistula (GBF) may appear some time after a primary LSG. The objective of this study was to characterize GBF after LSG and establish standardized treatment procedures. METHODS All patients undergoing surgery for GBF after LSG at a public university medical center in France between November 2004 and January 2013 were included in this study. Surgical and perioperative care was standardized. The primary efficacy criterion was the complication rate. Secondary efficacy criteria were the mortality rate, surgical data, types of complications, and the length of stay (LOS) in hospital. RESULTS Six patients were treated for GBF after LSG: 2 presented GBF after primary LSG performed in our institution and 4 had been referred by tertiary centers. The median (range) time to onset of GBF after LSG was 136 days (99-238 d). Preoperative refeeding was performed in 5 cases. The median time interval between the discovery of GBF and its surgical treatment was 31 days (7-137 d). Five patients underwent simultaneous abdominal and thoracic procedures. The abdominal procedures consisted of total gastrectomy (n = 1) and 60-cm Roux-en-Y gastrojejunal anastomosis (n = 6). There were no postoperative mortalities. Four postoperative complications occurred (66.6%), 2 of which were postoperative fistulas (33.3%) requiring revisional surgery. The median time to oral refeeding was 10 days (8-65 d) and the median LOS was 14 days (13-25 d). CONCLUSIONS Our treatment of GBF is based on effective drainage with endoscopic procedures, allowing optimal preoperative refeeding before combined abdominal and thoracic surgery. For the abdominal procedure, we prefer a 60-cm Roux-en-Y gastrojejunal anastomosis to total gastrectomy, because the former is simpler and minimizes the long-term risk of postoperative malabsorption.

Laparoscopic sleeve gastrectomy in patients with NASH-related cirrhosis: A case-matched study

BACKGROUND Laparoscopic sleeve gastrectomy (SG) is a validated procedure for the surgical treatment of morbid obesity. Cirrhosis is often considered a relative contraindication to elective extrahepatic surgery. The objective of this study was to evaluate the morbidity related to SG performed in cirrhotic patients compared with noncirrhotic patients. METHODS Between March 2004 and January 2013, we included all patients with cirrhosis undergoing SG (13 patients). These patients (SG-cirrhosis group) were matched in terms of preoperative data (age, gender, body mass index, and co-morbidities) on a 1:2 basis, with 26 noncirrhotic patients (SG group) selected from a population of 750 patients. Cirrhosis was diagnosed postoperatively on histologic exam. The primary endpoint was the overall postoperative complication rate. Secondary endpoints were operating time, revisional surgery rate, gastric fistula and bleeding rates, postoperative mortality, and weight loss over a 24-month period. RESULTS The SG-cirrhosis group consisted of 13 patients with a median age of 52 years. All patients in the SG-cirrhosis group were Child A. Etiology of cirrhosis was related to NASH in 93.3%. Median operating time in the SG-cirrhosis group and SG group was 75 minutes versus 80 minutes (P = .59). No postoperative mortality was observed in either group. The overall postoperative complication rate was 7.7% versus 7.7% (P = 1). The major complication rate was 0% versus 7.7% (P = .22), and the postoperative gastric fistula rate was 0% versus 3.8% (P = .47). No complications related to cirrhosis were reported. CONCLUSION SG can be performed in Child A cirrhosis with no increased risk of postoperative complications and no specific complications related to cirrhosis. Weight loss for patients with cirrhosis undergoing SG is similar to that observed in noncirrhotic patients.

Paradoxical articular manifestations in patients with inflammatory bowel diseases treated with infliximab.

Introduction Articular involvement is the most common extraintestinal manifestation associated with inflammatory bowel diseases (IBDs). Manifestations are ‘paradoxical’ when they occur during treatment, notably with anti-tumor necrosis factor (anti-TNF) drugs, which are expected to prevent or treat them. The aim of this study was to assess the frequency, characteristics, and associated factors of paradoxical articular manifestations in patients with IBD treated with anti-TNF. Patients and methods In this prospective single-center study, an examination by a rheumatologist was systematically offered to all patients with IBD treated with infliximab (IFX) to assess the prevalence of articular manifestations and distinguish between those related to treatment and those associated with intestinal disease. Paradoxical manifestations were defined as the occurrence of articular manifestations (excluding induced lupus and hypersensitivity reactions) during anti-TNF therapy in patients with intestinal remission. Measures of biological inflammatory, immunological markers, HLA-B27 allele, IFX trough levels, and anti-IFX antibody (Ab) were performed for all patients. Results Between May 2013 and April 2014, 65 patients with Crohn’s disease and 15 with patients ulcerative colitis treated with IFX were included. The median duration of anti-TNF therapy was 66 months [quartile (Q)1=23 months–Q3=81 months]. Articular manifestations were observed in 50 (62%) patients treated with IFX. Eleven percent (n=9) were considered to be associated with IBD and 16% (n=13) to be associated with anti-TNF therapy. Among articular manifestations associated with anti-TNF therapy, nine (11%) patients were considered paradoxical, two (2%) as drug-induced lupus, and two (2%) as a hypersensitivity reaction. Among the nine patients with paradoxical manifestations, all had Crohn’s disease in clinical remission, three patients presented a spondyloarthropathy, and three developed associated paradoxical psoriasis. No patient discontinued anti-TNF because of the articular manifestations. Methotrexate was effective on articular symptoms in two of the three treated patients with paradoxical manifestations. No clinical or biological factors, including IFX trough levels, were associated with the occurrence of paradoxical manifestations. Conclusion Paradoxical articular manifestations in IBD patients treated by anti-TNF are common, affecting more than 10% of patients. These events are generally mild and do not need discontinuation of anti-TNF therapy.

Persistent gastric fistula after sleeve gastrectomy: an analysis of the time between discovery and reoperation

BACKGROUND Gastric leak (GL) represents one of the main early-onset postoperative complication of sleeve gastrectomy (SG). Most studies of GL featured short series and no data on the time to reoperation for persistent GL. OBJECTIVES Characterize the time between discovery of persistent post-SG GL and the implementation of reoperation. SETTING University hospital, France, public practice. METHODS All patients treated for post-SG GL between November 2004 and December 2013 were included. The primary efficacy criterion was the time interval between discovery of a persistent GL and reoperation. The secondary efficacy criteria were demographic, surgical, and endoscopic data; mortality rate; time to GL healing; treatment success rate; and risk factors for failure treatment. RESULTS Eighty-six patients were treated for post-SG GL. Forty patients (46.5%) had early-onset GL (postoperative day ≤ 7). Two patients (2.3%) presented primary gastrobronchial fistula. Fifty-six patients (70%) underwent immediate reoperation. Endoscopic treatment was required to treat the GL in 92.7% of the cases (n = 77). The mortality rate was 1.2% (n = 1). The treatment success rate was 89.1%. The median time to healing GL was 84 days (14-423 d). Eighty percent of the GLs had healed 120 days after discovery. After 120 days, the incidence of complications related to GL increased and few additional GLs healed. The only identified risk factor for treatment failure was large retained gastric fundus (P ≤ .05). CONCLUSIONS Most cases of GL can be adequately treated by incorporating endoscopic stenting. Surgery for persistent GL should be performed within 120 days of discovery; after this cut-off, the incidence of GL-related complications increases. Large retained gastric fundus is a risk factor for treatment failure and may prompt the surgeon to consider earlier reoperation.

Outpatient laparoscopic sleeve gastrectomy: first 100 cases

STUDY OBJECTIVE The development of outpatient surgery was one of the major goals of public health policy in 2010. The purpose of this observational prospective study was to evaluate the feasibility of laparoscopic sleeve gastrectomy (SG) in an ambulatory setting. DESIGN Study design was a prospective prospective observational, nonrandomized study, registered (ClinicalTrials.gov identifier: NCT01513005), with institutional review board approval and written informed consent. SETTING Amiens University Medical Center. PATIENTS Patients undergoing SG who were preselected by inclusion ambulatory criteria. INTERVENTIONS All patients operated on for obesity by laparoscopic SG, from May 2011 through July 2013. MEASUREMENTS We collected outcomes data on 100 patients including incidence of postoperative nausea and vomiting, maximum and average pain scores, and the overall satisfaction rate. MAIN RESULTS Of the 100 obese patients, 93% were women. The mean age was 36 years (22-55 years). The mean preoperative body mass index was 42.4 kg/m(2). The mean operating time was 60 minutes (range, 30-95 minutes). The overall satisfaction rate was 93% (n = 93). When leaving the postoperative care unit, 94% of patients felt no or mild pain. Eighty-two percent had no postoperative postoperative nausea and vomiting, and 7 patients needed treatment using ondasetron. CONCLUSIONS Laparoscopic SG in an ambulatory setting is feasible with a dedicated anesthesiological approach and an expert surgical team. Appropriate patient selection is important for ensuring safety and quality of care within the outpatient program.

Is sleeve gastrectomy still contraindicated for patients aged≥60 years? A case-matched study with 24 months of follow-up

BACKGROUND Current guidelines consider that bariatric surgery is relatively contraindicated in elderly adults (aged≥60 years). The objective of this study was to evaluate obesity-related morbidity after sleeve gastrectomy (SG) according to whether patients were aged≥60 years or<60 years. METHODS Forty-two patients aged≥60 years (the elderly group) were matched 1:2 with 84 patients aged<60 (the control group). The primary objective was to compare weight change and the remission rate of co-morbidities in the 2 groups after 24 months of follow-up. The secondary endpoints were short-term and midterm postoperative outcomes (operating time, the frequency of conversion to laparotomy, the length of hospital stay, postoperative complications, mortality, and the SG failure rate). RESULTS No significant differences were observed between the elderly and control groups in terms of the mean operating time (83 minutes in both groups; P = .90), length of stay (3.2 versus 3.4 days, respectively; P = .51), morbidity rate (4.7% versus 9.5%, P = .35), or mortality rate (0% in both groups). The mean excess weight loss was significantly lower in the elderly group than in the control group at 12 months (56.2% versus 71.4%, respectively; P<.01) and 24 months (51.8% versus 73.5%, P<.01). Similar statistically significant differences were observed between the elderly group and control group for remission of metabolic syndrome (95% versus 90%, respectively; P = .55), type 2 diabetes mellitus (87% versus 71%, respectively; P = .13), hypertension (81% versus 77%, respectively; P = .71), and dyslipidemia (94% versus 74%, respectively; P = .09) at 24 months after SG. CONCLUSION Results support the safety and efficacy of SG for morbid obesity in patients aged≥60 years. In contrast to weight loss, the long-term morbidity rate and remission of obesity-related co-morbidities were similar in the participants aged≥60 years and those aged<60 years.

Three-dimensional computed tomography analysis of the left gastric vein in a pancreatectomy

BACKGROUND During a pancreatectomy, the left gastric vein (LGV) has an important role in the venous drainage of the stomach (total pancreatectomy, left splenopancreatectomy, pancreatoduodenectomy with venous resection and pylorus-preserving pancreaticoduodenectomy). Pre-operative knowledge of the LGVs termination is necessary for adequate protection of this vein during dissection. The objective of the present study was to analyse the location of the LGVs termination in a patient population and facilitate its identification in at-risk situations. MATERIALS AND METHODS Abdominal computed tomography (CT) images of 86 pancreatic tumour patients (20 of whom underwent surgery), who were treated in our institution between October 2009 and October 2010, were reviewed. Arterial-phase and portal-phase helical CT with three-dimensional reconstruction was performed in all cases. The location of the termination of the LGV was determined and (when the LGV merged with the splenic vein or the splenomesenteric trunk) the distance between the termination and the origin of the portal vein (PV). The correlation between CT imaging data and intra-operative findings was studied. RESULTS The LGV was identified on all CT images. In 65% of cases (n= 56), the LGV terminated in the PV (upstream of the liver in nine of these cases). The LGV terminated at the splenomesenteric trunk in 4.7% of cases (n= 4) and in the splenic vein in 30.3% of cases (n= 26). When the LGV terminated upstream of the origin of the PV, the distance between the two was always greater than 1 cm. The average distance between the termination of the LGV and the origin of the PV was 14.34 mm (10.2 to 21.1). The anatomical data from CT images agreed with the intra-operative findings in all cases. CONCLUSION Pre-operative analysis of the LGV is useful because the vein can be identified in all cases. Knowledge of the terminations anatomic location enables the subsequent resection to be initiated in a low-risk area.

The Short- and Long-term Outcomes of Pancreaticoduodenectomy for Cancer in Child a Patients Are Acceptable: a Patient-control Study from the Surgical French Association Report for Pancreatic Surgery

On the basis of now dated studies, cirrhosis is usually considered to be a contraindication in pancreatoduodenectomy (PD) for adenocarcinoma of the pancreatic head (APH).