Michel Vix

The Mechanism of Diabetes Control After Gastrointestinal Bypass Surgery Reveals a Role of the Proximal Small Intestine in the Pathophysiology of Type 2 Diabetes

Summary Background Data:Most patients who undergo Roux-en-Y gastric bypass (RYGB) experience rapid resolution of type 2 diabetes. Prior studies indicate that this results from more than gastric restriction and weight loss, implicating the rearranged intestine as a primary mediator. It is unclear, however, if diabetes improves because of enhanced delivery of nutrients to the distal intestine and increased secretion of hindgut signals that improve glucose homeostasis, or because of altered signals from the excluded segment of proximal intestine. We sought to distinguish between these two mechanisms. Methods:Goto-Kakizaki (GK) type 2 diabetic rats underwent duodenal-jejunal bypass (DJB), a stomach-preserving RYGB that excludes the proximal intestine, or a gastrojejunostomy (GJ), which creates a shortcut for ingested nutrients without bypassing any intestine. Controls were pair-fed (PF) sham-operated and untreated GK rats. Rats that had undergone GJ were then reoperated to exclude the proximal intestine; and conversely, duodenal passage was restored in rats that had undergone DJB. Oral glucose tolerance (OGTT), food intake, body weight, and intestinal nutrient absorption were measured. Results:There were no differences in food intake, body weight, or nutrient absorption among surgical groups. DJB-treated rats had markedly better oral glucose tolerance compared with all control groups as shown by lower peak and area-under-the-curve glucose values (P < 0.001 for both). GJ did not affect glucose homeostasis, but exclusion of duodenal nutrient passage in reoperated GJ rats significantly improved glucose tolerance. Conversely, restoration of duodenal passage in DJB rats reestablished impaired glucose tolerance. Conclusions:This study shows that bypassing a short segment of proximal intestine directly ameliorates type 2 diabetes, independently of effects on food intake, body weight, malabsorption, or nutrient delivery to the hindgut. These findings suggest that a proximal intestinal bypass could be considered for diabetes treatment and that potentially undiscovered factors from the proximal bowel might contribute to the pathophysiology of type 2 diabetes.

Transcontinental Robot-Assisted Remote Telesurgery, Feasibility and Potential Applications

ObjectiveTo show the feasibility of performing surgery across transoceanic distances by using dedicated asynchronous transfer mode (ATM) telecommunication technology. Summary Background DataTechnical limitations and the issue of time delay for transmission of digitized information across existing telecommunication lines had been a source of concern about the feasibility of performing a complete surgical procedure from remote distances. MethodsTo verify the feasibility and safety in humans, the authors attempted remote robot-assisted laparoscopic cholecystectomy on a 68-year-old woman with a history of abdominal pain and cholelithiasis. Surgeons were in New York and the patient in Strasbourg. Connections between the sites were done with a high-speed terrestrial network (ATM service). ResultsThe operation was carried out successfully in 54 minutes without difficulty or complications. Despite a round-trip distance of more than 14,000 km, the mean time lag for transmission during the procedure was 155 ms. The surgeons perceived the procedure as safe and the overall system as perfectly reliable. The postoperative course was uneventful and the patient returned to normal activities within 2 weeks after surgery. ConclusionsRemote robot-assisted surgery appears feasible and safe. Teletransmission of active surgical manipulations has the potential to ensure availability of surgical expertise in remote locations for difficult or rare operations, and to improve surgical training worldwide.

Safety of laparoscopic approach for acute cholecystitis : Retrospective study of 609 cases

Abstract. Laparoscopic cholecystectomy (LC) is now widely accepted as the modality of choice for the treatment of symptomatic uncomplicated cholelithiasis. The application of the laparoscopic technique in the setting of acute cholecystitis (AC) is more controversial. The precise role as well as the potential benefits of LC in the treatment of the acutely inflamed gallbladder have not been clearly established through large clinical series. The aim of our study was to assess the feasibility, safety, benefits, and specific complications of the laparoscopic approach in patients with AC. A retrospective chart analysis involving the patients admitted to two busy emergency digestive surgical units between October 1990 and December 1997 was carried out. Six hundred and nine patients meeting our criteria for AC were identified and evaluated. Overall complication rate was 15% with 12 postoperative bile leakages (1.97%) and 4 biliary tract injuries (BTI) (0.66%). The overall mortality rate was 0.66%. Local and overall complication rates were significantly correlated with the delay between the onset of acute symptoms and the operation but not the rate of general complications nor deaths. Our results demonstrate the safety and feasibility of LC in the setting of AC. Early cholecystectomy within 4 days is strongly recommended to minimize complications and increase the chances of a successful laparoscopic approach.

Two-stage totally minimally invasive approach for acute complicated diverticulitis.

Objectives  Surgical options for acute diverticulitis with peritonitis include Hartmanns procedure or resection and primary anastomosis with or without a stoma. Initial laparoscopic lavage and drainage can control the acute intra‐abdominal sepsis to allow for a delayed definitive procedure in nonemergency conditions. Potential advantages include the avoidance of a laparotomy, stoma and local infections at the origin of dehiscence and incisional hernias. We evaluated this approach in a selected group of patients.

Three-Dimensional Virtual Neck Exploration before Parathyroidectomy

The authors found that three-dimensional virtual neck exploration may be a valuable adjunct to presurgical planning. It can detect inapparent anatomical variations that permit modification of the planned surgical approach.

WeBSurg: An innovative educational Web site in minimally invasive surgery--principles and results.

Internet has dramatically changed clinical practice and information sharing among the surgical community and has revolutionized the access to surgical education. High-speed Internet broadcasting allows display of high-quality high-definition full-screen videos. Herein, Internet access to surgical procedures plays a major role in continuing medical education (CME). The WeBSurg Web site is a virtual surgical university dedicated to post-graduate education in minimally invasive surgery. Its results measured through its members, number of visitors coming from 213 different countries, as well as the amount of data transmitted through the provider LimeLight, confirm that WeBSurg appears as the first Web site in surgical CME. The Internet offers a tailored education for all levels of surgical expertise as well as for all types of Internet access. This represents a global multimedia solution at the cutting edge of technology and surgical evolution, which responds to the modern ethos of “always, anywhere, anytime.”

Late Gastric Prolapse with Pouch Necrosis after Laparoscopic Adjustable Gastric Banding

One of the most significant complications of the gastric banding procedure is gastric prolapse. However, pouch necrosis after gastric prolapse is an extremely rare complication. We present the case of a morbidly obese 41-year-old woman who had had a laparoscopic adjustable gastric banding procedure 3 years before. She developed a pouch necrosis after a late gastric prolapse. After failure of conservative treatment, a diagnostic laparoscopy was performed. This resulted in removal of the band and the diagnosis of pouch necrosis. A laparotomy was indicated and a sleeve gastrectomy was performed. A delay in the diagnosis of gastric prolapse can lead to major complications. Initial referral to a specialized center is necessary for proper care of this complication. Failure of conservative treatment mandates early operative intervention.

Laparoscopy in the Evaluation of Abdominal Stab Wounds

A retrospective study was designed to compare the accuracy and potential advantages of laparoscopy vs. laparotomy in the management of abdominal stab wounds. Thirty-five patients with abdominal stab wounds and scheduled for abdominal surgical exploration based on clinical evaluation were included. Hemodynamically unstable patients were excluded from the evaluation, laparotomy being performed immediately. Laparotomy was performed in 18 and laparoscopy in 17 patients. Penetrating wounds were observed in 65% of the patients (66.6% for laparotomy and 64.7% for laparoscopy). The diagnostic accuracy of laparoscopy was 100%, and laparotomy 89%. Four patients operated on by laparoscopy were converted to laparotomy (22%): in 2 patients to ascertain the origin of hemorrhage, and in 2 patients to suture a bowel laceration. No mortality was noted. Morbidity was observed in 4 patients managed by laparotomy: delirium tremens; pulmonary infection; missed small bowel injury, and stress bleeding ulcus. The postoperative hospital stay was significantly shorter for the patients explored by laparoscopy than for those explored by laparotomy (5.6 vs. 10.2 days, p = 0.02). We conclude that laparoscopy is a safe and accurate method for the evaluation of abdominal stab wounds. It avoids unnecessary laparotomy in 78% of cases. It led to less morbidity and shorter hospital stay than laparotomy. Further evaluation is required to determine the potential to treat major acute lesions by laparoscopy.

Management of staple line leaks after sleeve gastrectomy in a consecutive series of 378 patients.

Introduction: Laparoscopic sleeve gastrectomy (LSG) is gaining acceptance as a stand-alone bariatric procedure with proven efficacy on weight loss and obesity-related comorbidities. A specific and potentially severe complication of LSG is the staple line leak (SLL). Our aim was to report the SLL rate and its management in a prospective cohort of 378 LSGs. Patients and Methods: A total of 378 patients underwent LSG from July 2005 to July 2011. The gastric transection was performed by an initial 60 mm firing of 4.5 mm staples at the antrum and successive 60 mm firings of 3.5 mm staples at the gastric body and fundus toward the left diaphragmatic crus. A 36 Fr bougie was used to calibrate the gastric tube. The staple line was systematically reinforced with a partial-thickness running suture. Results: The overall complications and SLL rate were 20/378 (5.29%) and 9/378 (2.38%), respectively. SLLs were managed by laparoscopic (n=2) or open (n=1) exploration, drainage and endoscopic self-expandable covered stent, computed tomography–guided percutaneous drainage (n=2), or a self-expandable covered stent alone (n=4). Medical support including total parenteral nutrition and adapted antibiotics was started in all patients. The combined treatment modalities were successful in all cases. Conclusions: SLL was the most common complication of LSG accounting for half of the overall complications. Percutaneous drainage and self-covered stents combined with antibiotics and parenteral nutrition are effective for SLL and should be proposed as first-line treatment in stable patients.

Abordaje laparoscópico en el tratamiento de la colecistitis aguda: estudio retrospectivo en 609 casos

Resumen La colecistectomia laparoscopica (CL) es actualmente bien aceptada como el tratamiento de eleccion en la colelitiasis sintomatica no complicada. La aplicacion de la tecnica laparoscopica en pacientes con colecistitis aguda (CA) es mas controvertida. El exacto papel y los beneficios potenciales de la CL en el tratamiento de la CA no se han establecido claramente, ni existen amplias series clinicas. El objetivo del estudio fue valorar la aplicabilidad, seguridad, beneficios y complicaciones especificas del abordaje laparoscopico en pacientes con CA. Se realizo un analisis retrospectivo de los pacientes admitidos en dos unidades de cirugia digestiva de urgencia entre octubre de 1990 y diciembre de 1997. Se identificaron y evaluaron 609 pacientes que cumplieron los criterios de CA. La tasa de complicaciones fue del 15%, con 12 fistulas biliares postoperatorias (1,97%) y 4 lesiones de la via biliar (LVB) (0,66%). La mortalidad global fue del 0,66%. Las complicaciones locales y globales se correlacionaron significativamente con el retraso entre el inicio de los sintomas agudos y la cirugia, pero no asi la tasa de complicaciones generales ni la de fallecimientos. Nuestros resultados demuestran la seguridad y la factibilidad de la CL en la CA. La colecistectomia temprana dentro de los primeros 4 dias se recomienda ampliamente para minimizar las complicaciones e incrementar las posibilidades de un sabordaje laparoscopico con exito.