Nicolas Reibel

Perioperative outcomes after totally robotic gastric bypass: a prospective nonrandomized controlled study

BACKGROUND Perioperative short-term outcomes could be improved after totally robotic Roux-en-Y gastric bypass (TR-RYGBP) compared with conventional laparoscopic gastric bypass. METHODS This is a nonrandomized controlled prospective study (N = 200) to evaluate perioperative short-term outcomes. The primary endpoint was to investigate risk factors for 30-day surgical complications. RESULTS Mean total operative time was shorter in patients who underwent TR-RYGBP (130 vs 147 minutes; P < .0001). However, postoperative surgical complications rate (13% vs 1%; P = .001), and mean overall hospital stay (9.3 vs 6.7 days; P < .0001) were higher after TR-RYGBP. By multivariate analysis, robotic surgery (hazard ratio [HR] = 15.1; 95% confidence interval [CI], 2.8 to 280; P = .01), and conversion to laparotomy (HR = 18.8; 95% CI, 1.7 to 250.8; P = .014) were independent risk factors for 30-day surgical complications. CONCLUSIONS Although robotic gastric bypass reduces mean operative time, TR-RYGBP is associated with an increased postoperative surgical complications rate and longer hospitalization.

Pancreatic, endocrine and bariatric surgery: the role of robot-assisted approaches.

Please cite this article in press as: Brunaud L, et al. Pancreatic, endocrine and bariatric surgery: The role of robot-assisted approaches. Journal of Visceral Surgery (2011), doi:10.1016/j.jviscsurg.2011.05.006 surgery have also been carried by this groundswell. In 2010, surgery on all organs encompassed by the field of surgical endocrinology (pancreas and adrenal, parathyroid, and thyroid glands) is routinely performed by a minimally invasive laparoscopic approach, as is bariatric surgery [1—7]. For most surgeons, however, laparoscopy is still limited to procedures of relatively low (e.g., cholecystectomy or appendectomy) or intermediate (fundoplication, colectomy, splenectomy, or gastric bypass) complexity [8]. The causes of this limitation are mainly related to the technical difficulties encountered with laparoscopy, for which the surgeon uses long instruments without articulated ends, which thus provide only four degrees of freedom. Such instruments modify the performance of the surgical procedure as compared to open surgery, where surgeons can position their bodies and use their shoulders, elbows, wrists, and finger joints for optimal control of the surgical movements. In addition, the physician views laparoscopy on a two-dimensional screen, which has no depth of field; this makes some dissection and suturing procedures more difficult. The camera is not manipulated by the surgeon but by an assistant, which can also affect the quality of the field of vision. Finally, alignment of the visual field with the ends of the instruments is rarely achieved; this problem creates a significant fatigue factor that interferes with the precision of the surgeon’s hand movements [9]. In this context, the development of robotic surgery is part of a process intended to give patients the advantages of laparoscopy while endeavoring to overcome the aforesaid difficulties routinely encountered by laparoscopic surgeons. Robotic surgery consists of ‘‘simply’’ placing a computer interface between patient and surgeon to optimize the feasibility and quality of the surgical procedure. It is therefore actually laparoscopic surgery whose feasibility, indications, and results are ‘‘optimized’’ compared with conventional laparoscopic surgery [10].

Place de la laparoscopie dans la prise en charge des blessés par arme blanche de la paroi abdominale antérieure

Resume Introduction devant une plaie par arme blanche de la paroi abdominale, la difficulte est de determiner son caractere penetrant ou non. L’objectif cette etude etait de montrer que la coelioscopie est une methode efficace et sure pour determiner le caractere penetrant ou non d’une plaie abdominale par arme blanche. Methodes cette serie comprend 60 patients repartis en 4 groupes. Tous les patients ont beneficie d’une exploration coelioscopique. Selon les constations, les patients etaient repartis en 4 groupes. La laparotomie exploratrice n’etait realisee qu’en cas d’effraction peritoneale. Resultats une laparotomie inutile etait evitee chez 58 % des patients, avec une morbidite et une mortalite nulles. Aucune laparotomie secondaire n’a ete necessaire pour une lesion viscerale passee inapercue. Conclusion l’approche coelioscopique nous semble etre un moyen sur et efficace pour determiner le caractere penetrant ou non d’une plaie. En cas d’effraction peritoneale, une exploration par laparotomie est necessaire afin de ne pas meconnaitre une lesion viscerale associee.

Totally robotic gastric bypass

Bariatric surgery ensures significant and lasting weight loss in the morbidly obese. Thegoal of weight loss is to reduce the morbidity (diabetes, sleep apnea, arterial hyperten-sion, hyperlipidemia...) and mortality related to morbid obesity. A robotic device can beused solely for the gastrojejunostomy (robotic-assisted bypass) or, more logically, for theentire operation (totally robotic bypass). Weight loss after robotic surgery is similar to thatobtained in open or conventional laparoscopic surgery. However, morbidity and notably therisk of gastrojejunostomy leak may be reduced with robotic surgery [1].

Evaluation of risk factors for complications after bariatric surgery

The decision to perform a bariatric surgical procedure, the conclusion of a clinical pathway in which management is individually adapted to each patient, is taken after multidisciplinary consultation. Paradoxically, the patients who would most benefit from surgery are also those who have the highest operative risk. In practice, predictive factors of mortality and severe postoperative complications (Clavien-Dindo>III) must be used to evaluate the benefit/risk ratio most objectively. The main risk factors are age, male gender, body mass index, obstructive sleep apnea syndrome, insulin resistance and diabetes, tobacco abuse, cardiovascular disease, ability to lose weight before surgery, hypoalbuminemia and functional disability. Routine preoperative evaluation of high perioperative risk patients provides the attending physician with information to: (1) correct several of these risk factors before surgery and thereby limit the operative risk; (2) orient the patient to a less risky surgical procedure and/or to a facility with a more adapted technical capacity, as necessary; (3) contra-indicate the operation if the risks exceed the expected benefits. All in all, this preoperative evaluation combined with management of comorbidities contributes to decrease the risk of postoperative complications and to improve the overall management of obese patients.

Does Anatomy Explain the Origin of a Leak After Sleeve Gastrectomy? Comments & Answers

Dear Editors, We would like to thank Dr. El-shoek et al. for their comments and interest about our recently published paper on gastric leak after sleeve gastrectomy for morbid obesity (OBSU-D-13-00566—Does anatomy explain the origin of a leak after sleeve gastrectomy? Perez M, Brunaud L, Kedaifa S, Guillotin C, Gerardin A, Quilliot D, Grosdidier G, Reibel N. Obes Surg. 2014 Oct;24(10):1717–23). Please find below our answer for each of your questions or comments.

Totally robotic Roux-en-Y gastric bypass (with video).

Gastric bypass;Laparoscopy;Robotic surgery;Robotics;New technologiesThe prevalenceofmorbidlyobeseindividualsisrisingrapidly.Beingoverweightpredisposespatients to multiple serious medical comorbidities including type two diabetes, hyperten-sion, dyslipidemia, and obstructive sleep apnea. This video shows stepby a totallyrobotic Roux-en-Y gastric bypass in an obese patient(BMI42kg/m

O029 Carences en vitamines et oligo-éléments après gastroplastie et court circuit gastrique : corriger ou prévenir les carences ? Étude prospective sur 266 patients

Introduction et but de l’etude Apres chirurgie bariatrique, le risque de deficits en micro-nutriments est majeur en raison d’une diminution des apports (chirurgie restrictive) et/ou d’une diminution de l’absorption (chirurgie malabsorptive ou mixte). Materiel et methodes Nous avons evalue l’efficacite d’une prevention systematique des deficits en micro-nutriments par un melange de vitamines et d’oligo-elements, correspondant a 50 % des ANC, donne au long cours apres Court circuit Gastrique (CCG) et pendant 6 mois apres gastroplastie (GP). La prevention de la carence en Vit B12 etait faite apres CCG, grâce a une supplementation systematique par 1 000 μg /semaine par voie orale et apres gastroplastie, en cas de deficit avere. Le deficit en fer etait corrige au cas par cas lorsque la ferritine etait abaissee ( Resultats Vitamine B12 : La supplementation de 1000 μg en vit B12peros a ete suffisante chez 93 % des patients ayant un CCG. La dose a du etre doublee (2 000 μg/semaine) chez 5 % d’entre eux et le recours a la voie intramusculaire a ete necessaire dans 2 %. 5 % des patients GP ont eu un deficit en vit B12 et ont du prendre une supplementation. Fer : malgre la supplementation en fer en cas de deficit, en moyenne le taux de ferritine a diminue progressivement au cours des 5 annees de suivi apres GP comme apres CCG (en moyenne de 104,2 +/- 10 ng/ml a 70,5 +/- 8 ng/ml). 90 % des femmes avant menopause ayant beneficie d’un CCG ont eu besoin d’une supplementation discontinue en fer. Le deficit en zinc touchait selon les visites, 26 a 42 % de patients CCG et entre 12 et 24 % apres GP. Le deficit en selenium touchait selon les visites 26 a 33 % des CCG et 15 a 22 % des GP. Conclusions La prevention systematique de la carence en vit B12 par 1 000 μg/semaine per os parait suffisante pour prevenir les carences apres CCG. La prevalence de 5 % de deficit apres GP justifie un depistage de cette carence chez les patients dont les apports en aliments riches en vit B12 sont faibles (viande, produits laitiers, poisson). La supplementation en polyvitamines et oligo-elements est insuffisante pour eviter les deficits en oligo-elements. Une supplementation en fer systematique semble necessaire apres CCG et chez la femme non menopausee apres GP.