Michael John Chilcott

Short Versus Long Roux-Limb Length in Roux-en-Y Gastric Bypass Surgery for the Treatment of Morbid and Super Obesity: a Systematic Review of the Literature

Because of an important burden of disease, obesity is a major public health challenge in the twenty-first century. Where medico-psychological management has shown its limitations, bariatric surgery is now acknowledged as the most efficient therapy potentially offered to severely obese patients. Among other options, Roux-en-Y gastric bypass (RYGBP) is the most frequently performed procedure. The objective of this review is to systematically evaluate the effect of the Roux- (alimentary) limb length on postoperative weight loss after RYGBP in severely obese patients. MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched using terms related to Roux-limb, gastric bypass and obesity. To be included, studies had to be either randomized controlled trials, quasi-randomized controlled trials or prospective cohort studies comparing a shorter to a longer Roux-limb. Studies were critically appraised with regard to methodological components. Eight studies were reviewed. Variations in methodology, operation design and outcome assessment among studies caused considerable clinical heterogeneity, preventing us from performing a meta-analysis. The overall quality was questionable, owing to lack of rigor in methodological components reporting. Results were heterogeneous, but we identified a trend supporting that the construction of a longer Roux-limb is more efficient in super obese patients. This review suggests that the tailoring of a longer Roux-limb might only be efficient in super obese patients. The overall limited quality of the included studies prompts to call for improvement in trial design in surgery.

Surgical treatment of sacrococcygeal pilonidal sinus disease by excision and skin flaps: the Toulouse experience

OBJECTIVE To compare various techniques for the treatment of pilonidal sinus. DESIGN Retrospective study SETTING University Hospital of Toulouse, France. SUBJECTS 246 consecutive patients who presented between 1979 and 1996. The male:female ratio was 2:1, and the mean age 26 years (range 18-69). INTERVENTIONS 218 one or two stage excision and rotation skin flaps, and 28 simple incisions. RESULTS 16 sinuses recurred, and no flaps necrosed. CONCLUSION Excision and rotation skin flaps offers an effective and elegant alternative to the more classic operations for pilonidal sinus as it causes less postoperative pain and shortens convalescence.

Paraganglioma of the ampulla of Vater: a potentially malignant neoplasm.

Paragangliomas are rare tumours originating from neuroectodermic remnants and are usually considered as benign. We present two cases of paraganglioma of the ampulla of Vater that were treated surgically by pancreaticoduodenectomy. In one case, histopathology revealed malignant characteristics of the tumour with invasion of the pancreas and simultaneous duodenal lymph‐node metastases. Both patients had a favourable outcome without disease recurrence at 40 and 44 months postoperatively. Only 21 cases of ampullary paraganglioma have been reported in the literature, 7 of them with malignant characteristics. In conclusion, paragangliomas of the ampulla of Vater have malignant potential. Surgical therapy of these tumours should not be limited to local resection, as disease recurrence and lymph node involvement have been reported. We propose that paragangliomas of the ampulla of Vater should be operated by cephalic pancreaticoduodenectomy, which allows long‐term and disease‐free survival.

Preoperative counts of CD4 T-lymphocytes and early postoperative infective complications in HIV-positive patients.

OBJECTIVE To assess the relationship between postoperative infective complications and the CD4 count. DESIGN Retrospective and biometric study. SETTING Two university hospitals, Switzerland. SUBJECT 40 HIV-positive patients who had had CD4 counts done during the three months before operation. INTERVENTIONS Clean and contaminated gastrointestinal and orthopaedic procedures. MAIN OUTCOME MEASURE Postoperative infective complications. RESULTS 15 patients developed postoperative infective complications (38%), 6 of which (40%) were HIV-related. CD4 cell count, as well as the type of operation (contaminated or clean), influenced the infective complication rate. The risk of infective complications after a contaminated procedure when the CD4 count was below 200 mm3 was more than 50%. In clean operations, even when the CD4 cell count was close to 0, the rate of infective complications was never as high as 50%. Patients with a CD4 cell count of 500 or more have a similar rate of infective complications as HIV seronegative patients. CONCLUSION Indications for operation in HIV-positive patients must take into account the CD4 cell count and the type of operation.

Altemeier's procedure for rectal prolapse: analysis of long-term outcome in 60 patients.

Aim  Altemeier’s procedure (perineal rectosigmoidectomy) is the operation of choice for rectal prolapse in the elderly. The aims of this prospective observational study were to evaluate its long‐term actuarial recurrence risk and the influence of the length of rectosigmoid resection and associated levatorplasty on recurrence rate and continence.

Bouveret's Syndrome: Management and Strategy of a Rare Cause of Gastric Outlet Obstruction

Dear Sir, Bouveret’s syndrome is a subgroup (less than 1%) of gallstone ileus in which a cholecystoduodenal fistula allows the passage of a stone that obstructs the duodenum and causes gastric outlet obstruction [1] . Since the first description by Léon Bouveret in 1896, fewer than 200 cases have been described in the worldwide literature [2] . Although there are little data about the outcome of Bouveret’s syndrome, the mortality rate due to gallstone ileus was nearly 50%, but in recent years has improved to about 15% [3] . This high mortality may be related to the advanced age of the typical patient as well as other comorbidities [4, 5] . The decrease in morbidity in recent years likely represents the impact of endoscopic treatment option in lieu of surgery as well as early diagnosis with non invasive imaging [4] . Thus, the importance of a correct preoperative diagnosis and management is the key in this rare pathology. We here report on a case of Bouveret’s syndrome and propose an algorithm for the therapeutic strategy. A 78-year-old man with unremarkable past medical history complained of loss of appetite, and sensation of early repletion for 3 weeks. Physical examination was unspecific with mild epigastric tenderness. Laboratory values revealed only mild leukocytosis (11 g/l) and increased gammaPublished online: April 10, 2007

Optimization of the Kinetics of Cooling of Kidneys: A Pig Model

We determined the kinetics of cooling in multiple organ procurement for the kidney in a pig model. A biometric analysis by regression enables us to define the factors which influence the rate of temperature decrease: weight of the donor, average rate of perfusion and difference of temperature between the rectal temperature and the temperature of the perfusion solution at initiation of cooling. The description of the temperature as a function of time follows an exponential model of the type T(t) = T₀·edt where d is the rate of decrease. The rate of decrease varies according to the above factors. The cellular viability ratio (CVR), was correlated to the rate of cooling. The mean CVR was 91% (SD 4.95) when the rate of cooling was more than 1°C/min. This was compared to 75% (SD 11.17) when the rate was less than 1°C/min (p = 0.023). Our experience leads us to believe that the average cooling rate is frequently too low (<1°C/min). This model can be used to predict and control the kinetics of cooling and may help to define the best way of cooling for future xenotransplantation.

Medical Problems Occurring During the Long-term Follow-up after Liver Transplantation

Liver transplantation is a standardized therapy for end-stage liver disease. With current immunosuppressive protocols and patient care, ten-year patient survival rate has reached 60%. Several medical complications may develop during this period, including renal dysfunction, hypertension, diabetes mellitus, hyperlipidemia, and metabolic bone disease. The aim of this article is to analyze long-term results of several clinical trials reporting common medical dysfunctions after liver transplantation and to discuss their management.

Isolated Blunt Splenic Trauma in Adults

Several CT scan scores have been proposed to discriminate between splenic injuries requiring surgical intervention, and those that may be treated conservatively. The aim of this study is to compare th