Olivier Brehant

Results of laparoscopic sleeve gastrectomy: A prospective study in 135 patients with morbid obesity

BACKGROUND Sleeve gastrectomy is a new restrictive bariatric procedure increasingly indicated in the treatment of morbid obesity. The authors report their experience of laparoscopic sleeve gastrectomy (LSG), evaluate the efficacy of this procedure on weight loss, and analyze the short-term outcome. METHODS The data of 135 consecutive patients undergoing LSG between July 2004 and October 2007 were analyzed prospectively. LSG was indicated only for weight reduction with a body mass index (BMI) > 40 or > 35 kg/m(2) associated with severe comorbidity. Study endpoints included mean BMI, comorbidity, operative data, conversion to laparotomy, intraoperative complications, major and minor complication rates, excess weight loss, follow-up, and duration of hospital stay. Possible risk factors for postoperative gastric fistula (PGF) were investigated. RESULTS This series comprised 113 females and 22 males with a mean age of 40 years (range, 18-65). Mean weight was 132 kg (range, 94-186), and mean preoperative BMI was 48.8 kg/m(2) (range, 37-72). The mean operating time was 103 minutes (range, 30-550). No patients required conversion to laparotomy, and 96% of patients did not require drainage. The nasogastric tube was removed on postoperative day 1. The postoperative course was uneventful in 94.9% of cases, and the median duration of hospital stay was 3.8 days. The median follow-up was 12.7 months. The mean postoperative BMI decreased to 39.8 kg/m(2) at 6 months (P < .001). Average excess body weight loss was 38.6% and 49.4% at 6 months and 1 year, respectively. There was no mortality, and the major complication rate, corresponding to gastric fistula (PGF) in every case, was 5.1% (n = 7). Management of PGF required reoperation, radiologic and endoscopic procedures, and fibrin glue; the median hospital stay was 47 days. BMI > 60 kg/m(2) appears to be a risk factor for PGF. CONCLUSION LSG is a reproducible and seems to be an effective treatment to achieve significant weight loss after 12 months follow-up. LSG can be used as a standalone operation to obtain weight reduction. Management of PGF remains a major issue.

Is stenting as "a bridge to surgery" an oncologically safe strategy for the management of acute, left-sided, malignant, colonic obstruction? A comparative study with a propensity score analysis.

Objective and Background:Self-expanding metallic stent (SEMS) insertion has been suggested as a promising alternative to emergency surgery for left-sided malignant colonic obstruction (LMCO). However, the literature on the long-term impact of SEMS as “a bridge to surgery” is limited and contradictory. Methods:From January 1998 to June 2011, we retrospectively identified patients operated on for LMCO with curative intent. The primary outcome criterion was overall survival. Short-term secondary endpoints included the technical success rate and overall success rate and long-term secondary endpoints included 5-year overall survival, 5-year cancer-specific mortality, 5-year disease-free survival, the recurrence rate, and mean time to recurrence. Patients treated with SEMS were analyzed on an intention-to-treat basis. Overall survival was analyzed after using a propensity score to correct for selection bias. Results:There were 48 patients in the SEMS group and 39 in the surgery-only group. In the overall population, overall survival (P = 0.001) and 5-year overall survival (P = 0.0003) were significantly lower in the SEMS group than in the surgery-only group, and 5-year cancer-specific mortality was significantly higher in the SEMS group (48% vs 21%, respectively (P = 0.02)). Five-year disease-free survival, the recurrence rate, and the mean time to recurrence were better in the surgery-only group (not significant). For patients with no metastases or perforations at hospital admission, overall survival (P = 0.003) and 5-year overall survival (30% vs 67%, respectively, P = 0.001) were significantly lower in the SEMS group than in the surgery-only group. Conclusions:Our study results suggest worse overall survival of patients with LMCO with SEMS insertion compared with immediate surgery.

Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) has a specific morbidity profile in which gastric leak (GL) is the main complication. With a view to defining a standardized protocol for GL management, the present retrospective study sought to describe the clinical patterns of post-LSG GL and treatment of the latter in our university medical center. From July 2004 to December 2010, 25 patients were included. GL was described in terms of clinical presentation, time to onset, and location in the staple line. Treatment of GL with pharmacologic, radiologic, endoscopic, and/or surgical procedures was always validated by a multidisciplinary care team. “Treatment success” was defined as the absence of contrast agent leakage on CT and endoscopy after removal of covered metallic stent or pigtail drains. Systemic inflammation and peritonitis were the main signs for early-onset GL (56%), whereas pulmonary symptoms and intra-abdominal abscesses revealed delayed-onset GL (44%). Surgery was always performed for early-onset GL. In the total study population, the median number of endoscopic procedures was five (range, 1–11) per patient, of covered SEMS was three (range, 1–8), and of pigtail drains was three (range, 1–4). Nine (36%) patients presented endoscopic-related complications. Four (16%) patients with treatment failure underwent radical surgery. The mortality rate was 4% (n=1). The management of post-LSG GL is challenging. Surgery was always performed for early-onset GL, whereas treatment of delayed-onset GL was based on endoscopy. Pigtail drains required fewer procedures per patient, were better tolerated, and had lower morbidity–mortality than covered SEMS.

Polypose adénomateuse vésiculaire et syndrome de Gardner : une association rare

Resume Nous rapportons une observation de polypose adenomateuse vesiculaire chez une malade de 57 ans atteinte d’un syndrome de Gardner, decouverte au decours d’un episode d’angiocholite. A l’examen anatomo-pathologique, la vesicule renfermait deux calculs et comportait une multitude d’adenomes plans ou polypoides, de moins d’un centimetre, presentant des lesions de neoplasie intra-epitheliale de bas et de haut grade. Seul dix cas d’adenomes vesiculaires ont ete rapportes dans la litterature chez des malades ayant une polypose adenomateuse familiale (PAF). La cholecystectomie etait habituellement realisee en raison de symptomes evocateurs de cholecystite ou d’angiocholite. La pathogenie des lesions est encore mal connue. Ces lesions adenomateuses vesiculaires sont souvent decouvertes apres 40 ans. Leur risque de degenerescence est difficile a evaluer : seules six observations d’adenocarcinome vesiculaire chez des malades atteints de PAF etant rapportees dans la litterature.

Double L-shaped free-style perforator flap for perineal and vaginal reconstruction after cylindrical abdominoperineal resection.

The improvement of patient carcinological status by an abdominoperineal resection by extended posterior perineal approach in a prone position requires the plastic surgeon to consider other reconstructive options. We present an original double L-shaped free-style propeller flap used to reconstruct the vagina and the perineum of a 57-year-old patient after the resection of a T4 tumour of the lower rectum.

Technique of open laparoscopy for supramesocolic surgery in obese patients

BackgroundIncidence of obesity and related diseases are increasing in the world. Visceral surgeons are more often confronted with laparoscopic surgery in obese patients. Besides validated surgery procedures, such as cholecystectomy and gastroesophageal reflux surgery, bariatric procedures are increasingly performed. In obese patients, the thickness of adipose panicle makes open laparoscopy hazardous.MethodsIn our department, we use systematically a technique of open laparoscopy in obese patients for supramesocolic surgery, which is safe, reproducible, and permits good closure of the abdominal wall.ResultsThe surgical technique consists of opening the abdominal wall through the rectus abdominis. Helped by specific retractors called Descottes® (Medtronic Laboratory), both fascias are charged by sutures separately. Incision in the fascias is made safely by pooling on sutures. Introduction of port-site is made under view control. At the end of laparoscopy, closure of both fascias is easily done.ConclusionsWe present a technique of open laparoscopy in obese patients, systematically used, for supramesocolic surgery. This technique is safe, reproducible, and permits an efficient closure of the abdominal wall.

Colorectal carcinoma with potentially resectable metastases: Factors associated with the failure of curative schedule

BACKGROUND The management of patients with colorectal cancer (CRC) and synchronous liver metastases (SLM) depends on the primitive tumor, resectability of the metastatic disseminations and the patients comorbid condition(s). Considering all patients with potentially resectable primary CRC and SLM, curative resection (R0) will be possible in some patients, although in others surgery will never be performed. The purpose of our study was to identify factors of failure of the curative schedule in these patients. METHODS We reviewed the data of patients with CRC and SLM between January 2002 and March 2007. Two groups were defined: group R0 when complete metastatic and primary tumor resection was finally achieved after one and more surgical stages and group R2 when curative resection was not possible at the end of the schedule. Clinical, pathologic and outcome data were retrospectively analyzed as well as preoperative management of SLM (chemotherapy, radiofrequency, portal vein embolization). RESULTS Forty-five patients were included. Curative resection (group R0) was performed in 31 patients (69%) with 48% undergoing major hepatic resection. Mortality of hepatic resection was 0% although it was 9% for primitive tumor. Portal vein embolization was performed preoperatively in eight patients and radiofrequency ablation in 13. Median follow-up was 21 months. Overall survival was 86% at one year and 39% at three years. Survival in group 1 was 97 and 57% at one and three years respectively. Disease-free survival was 87 and 40% at one and three years. Tumor recurrence was noted in 61% of resected patients. At multivariate analysis, number of hepatic metastases superior than three and complicated initial presentation of primitive tumor were found to be significant and predictors of failure of hepatic resection. CONCLUSION Aggressive management with curative resection of SLM may enable long-term survival. More than three SLM and complicated initial presentation of primitive tumor are factors predictive of failure of the curative schedule.

Prise en charge chirurgicale de la pancréatite chronique

Resume Les indications chirurgicales de la pancreatite chronique peuvent etre schematiquement separees en cinq grands groupes : la douleur, les consequences de la fibrose sur les organes de voisinage, les consequences de la rupture canalaire en amont d’un obstacle, et la suspicion de cancer. Enfin, les malades chez qui les procedures endoscopiques sont impossibles (papille non accessible) ou trop rapprochees representent un dernier groupe d’indication chirurgicale. Les interventions sont multiples. Il peut s’agir d’interventions de derivation pancreatique, kystique, biliaire ou d’interventions dites mixtes (combinant derivation/resection) ou d’interventions de resection pancreatique. Enfin il peut s’agir d’intervention de denervation. Quelle que soit l’indication, le traitement chirurgical doit repondre a plusieurs objectifs : son indication doit etre discutee de facon multidisciplinaire ; il doit etre associe a une faible morbimortalite, et preserver au mieux la fonction endocrine ; il doit de facon claire ameliorer la qualite de vie, et avoir ete evalue a long terme, au mieux de facon prospective. Nous nous proposons de preciser quelques points importants pour la prise en charge de malades ayant une pancreatite chronique (PC), avant d’aborder les divers traitements de facon detaillee.

Giant cell vasculitis in the stroma of colonic adenocarcinomas: an unusual microscopic feature

immunohistochemistry when activated and forming part of a thrombus. Microthrombi play a pathological role in renal pathology, a still largely unrecognized role in vascular liver disease, e.g. the development of nodular regenerative hyperplasia, and occur throughout all organs as part of disseminated intravascular coagulation. CD31 stains thrombi in post-mortem tissue, surgical specimens and biopsy specimens (Figure 1). Its use improves the recognition of thrombi, more being readily apparent with CD31 than on haematoxylin and eosin sections and more reliable than with the use of MSB.

A Pitfall in the Diagnosis of Unresectable Liver Metastases: Multiple Bile Duct Hamartomas (von Meyenburg Complexes)

Von Meyenburg complexes (VMC) are a cluster of benign liver malformations including biliary cystic lesions, with congenital fibrocollagenous stroma. This rare entity can mimick multiple secondary hepatic lesions. We report a case of a 56-year-old woman who had multiples liver lesions 12 years after operation for breast cancer. Biopsy of the hepatic lesion confirmed the diagnosis of VMC. Preoperative discovery of multiple gray-white nodular lesions scattered on the surface of the liver should not always contraindicate curative liver resection. The diagnosis of VMC should be known and confirmed with liver biopsy.