Olivier Huber

Reducing cost of surgery by avoiding complications: the model of robotic Roux-en-Y gastric bypass.

BackgroundRobotic surgery is a complex technology offering technical advantages over conventional methods. Still, clinical outcomes and financial issues have been subjects of debate. Several studies have demonstrated higher costs for robotic surgery when compared to laparoscopy or open surgery. However, other studies showed fewer costly anastomotic complications after robotic Roux-en-Y gastric bypass (RYGBP) when compared to laparoscopy.MethodsWe collected data for our gastric bypass patients who underwent open, laparoscopic, or robotic surgery from June 1997 to July 2010. Demographic data, BMI, complications, mortality, intensive care unit stay, hospitalization, and operating room (OR) costs were analyzed and a cost projection completed. Sensitivity analyses were performed for varied leak rates during laparoscopy, number of robotic cases per month, number of additional staplers during robotic surgery, and varied OR times for robotic cases.ResultsNine-hundred ninety patients underwent gastric bypass surgery at the University Hospital Geneva from June 1997 to July 2010. There were 524 open, 323 laparoscopic, and 143 robotic cases. Significantly fewer anastomotic complications occurred after open and robotic RYGBP when compared to laparoscopy. OR material costs were slightly less for robotic surgery (USD 5,427) than for laparoscopy (USD 5,494), but more than for the open procedure (USD 2,251). Overall, robotic gastric bypass (USD 19,363) was cheaper when compared to laparoscopy (USD 21,697) and open surgery (USD 23,000).ConclusionsRobotic RYGBP can be cost effective due to balancing greater robotic overhead costs with the savings associated with avoiding stapler use and costly anastomotic complications.

Surgical management of gastrointestinal stromal tumours

Over the past decade, gastrointestinal stromal tumours (GISTs) have served as a model for the application of tyrosine kinase inhibitors in the treatment of solid neoplasms. Operative and medical management of GISTs is rapidly evolving, but current guidelines appear restricted to basic non‐organ‐specific recommendations.

Factors influencing energy intake and body weight loss after gastric bypass.

Objective: The gastric bypass-induced quantitative and qualitative modifications of energy intake (En In, kcal/day) and their impact on body weight (bw) loss were evaluated. The factors influencing energy intake and body weight loss were also investigated.Design: Longitudinal study.Setting: University Hospital of Geneva.Subjects: Fifty obese women undergoing a Roux-en-Y gastric bypass.Results: The reduction of EnIn was significantly related to bw loss expressed either in kg or as percentage correction of excess bw (P<0.01 for both), whereas the post-operative modifications of diet composition did not play a role. Age and initial bw significantly influenced bw loss (P<0.0001 and P<0.001, respectively), as shown by multiple regression analysis. Patients were divided into four sub-groups according to their age (under or over 35 y) and initial bw (under or over 120 kg). ANOVA showed that under 35-y-old subjects reduced their EnIn significantly more than their older counterparts having similar bw (P<0.02 and P<0.05); consequently, bw loss, expressed in kg, was significantly (P<0.0001 and P<0.0005) larger in younger patients. Subjects with an initial bw over 120 kg lost significantly (P<0.001 and P<0.02) more weight as compared to patients with a smaller degree of obesity (under 120 kg) and similar age.Conclusions: Gastric bypass-induced body weight loss is mainly due to the reduction of EnIn, whereas the qualitative modifications of the diet do not play a role. Younger subjects have a greater capacity to reduce EnIn and, therefore, lose more weight. Pre-operative high degree of obesity leads to a larger weight reduction, probably because of a greater energy deficit.

Preoperative work-up in asymptomatic patients undergoing Roux-en-Y gastric bypass: is endoscopy mandatory?

Background: We aimed to determine before Roux-en-Y gastric bypass (RYGBP) in asymptomatic morbidly obese patients: 1) the prevalence of abnormal findings at upper gastrointestinal (UGI) endoscopy; 2) Helicobacter pylori (HP) status; 3) clinical consequences of these findings; and 4) associated costs. Methods: We retrospectively reviewed 468 consecutive patients, excluded those with UGI symptoms, drug intake or previous UGI endoscopy/surgery, and analyzed findings in the 319 remaining patients (68%). Results: There were abnormal findings in 147 patients (46%), including 54 hiatal hernias and 146 parietal (i.e. mucosal or submucosal) lesions. The most significant were 7 ulcers and 2 gastric polyposis. HP was detected (using CLO-test) in 124 patients (39%). Histopathological examination of biopsies was abnormal in 109/161 patients (68%), and disclosed mainly chronic gastritis (n=98). Abnormal findings were more frequent in HP-positive compared to HP-negative patients (94 vs 51%, P<0.001). Findings had clinical implications in only 4% of patients: delayed surgery (7 ulcers), prophylactic gastrectomy (2 gastric polyposis), unnecessary work-up (3 irrelevant/false-positive diagnoses), and inclusion in a screening program (1 Barretts esophagus). Mean cost of complete UGI work-up was 389 €/patient. Conclusion: Asymptomatic morbidly obese patients frequently harbour UGI lesions warranting UGI work-up before RYGBP. However, routine endoscopy presents drawbacks. We propose a less invasive strategy which reduces costs and limits false-positive results and the subsequent investigations that they require. In our series, it would have missed two gastric polyposis only, for which no formal recommendation has yet been issued. This strategy could be a valuable alternative to routine UGI endoscopy before RYGBP in asymptomatic patients.

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.

Long-term renal function after liver transplantation is related to calcineurin inhibitors blood levels

Abstract:  Background:  Renal dysfunction is common after liver transplantation (LT). The aim of our study was to assess the prevalence of renal dysfunction 5 yr after LT and to identify risk factors for the development of this complication.

Surgical management of abdominal and retroperitoneal Castleman's disease

BackgroundAbdominal and retroperitoneal Castlemans disease could present either as a localized disease or as a systemic disease. Castlemans disease is a lymphoid hyperplasia related to human Herpes virus type 8, which could have an aggressive behavior, similar to that of malignant lymphoid neoplasm mainly with the systemic type, or a benign one in its localized form.MethodsThe authors report two cases of localized Castlemans disease in the retroperitoneal space and review the current and recent progress in the knowledge of this atypical disease.Cases presentationThe two patients were young healthy women presenting with a hyper vascular peri-renal mass suggestive of malignant tumor. Both have been resected in-toto. One of them had an extensive resection with nephrectomy, while the second had a kidney preserving surgery. Pathological examination revealed localized Castlemans disease and surgical margins were free of disease. Postoperative course was uneventful, and after more than 5-years of follow-up no recurrences have been observed.ConclusionLocalized Castlemans disease should be considered when facing a solid hypervascular abdominal or retroperitoneal mass. A better knowledge of this disorder and its characteristic would help surgeon to avoid unnecessarily extensive resection for this benign disorder when dealing with abdominal or retroperitoneal tumors. Surgical resection is curative for the localized form, when complete, while splenectomy could be indicated for the systemic form.

Twelve key nutritional issues in bariatric surgery

In morbidly obese patients, i.e. body mass index ≥35, bariatric surgery is considered the only effective durable weight-loss therapy. Laparoscopic Roux-en-Y gastric bypass (LRYGBP), laparoscopic sleeve gastrectomy (LSG), and biliopancreatic diversion with duodenal switch (BPD-DS) are associated with risks of nutritional deficiencies and malnutrition. Therefore, preoperative nutritional assessment and correction of vitamin and micronutrient deficiencies, as well as long-term postoperative nutritional follow-up, are advised. Dietetic counseling is mandatory during the first year, optional later. Planned and structured physical exercise should be systematically promoted to maintain muscle mass and bone health. In this review, twelve key perioperative nutritional issues are raised with focus on LRYGBP and LSG procedures, the most common current bariatric procedures.

Tachykinins mediate contraction of the human lower esophageal sphincter in vitro via activation of NK2 receptors

The contractile response to natural tachykinins and selective peptide agonists for tachykinin receptors was studied in strips of circular smooth muscle of human lower esophageal sphincter in vitro. The effects of phosphoramidon, which inhibits neutral endopeptidase (EC.3.4.24.11) and of the non-peptide compounds, SR 48968 and CP-96,345, which selectively block NK1 and NK2 receptors, respectively, were also investigated. Substance P, neurokinin A and neurokinin B produced a concentration-dependent contractile response. The rank order of potency was neurokinin A > neurokinin B > substance P. Phosphoramidon (1 microM) potentiated the response to substance P without changing the order of potency of natural tachykinins. The NK2-selective agonist, ([ beta Ala8]neurokinin A-(4-10)), produced a concentration-dependent contraction. The NK1 ([Sar9,Met(O2)11]substance P, 1 microM) and NK3 ([MePhe7]neurokinin B, 1 microM) selective agonists, however, did not exert any contractile effect. The selective NK2 antagonist, SR 48968, potently inhibited in a concentration-dependent (10 nM-1 microM) manner the response to neurokinin A, without affecting the response to carbachol. The selective NK1 antagonist, CP-96,345 (1 microM), did not affect the response to neurokinin A. These results indicate that tachykinins contract the circular muscle of human lower esophageal sphincter, and that this effect is mediated by NK2 receptor stimulation. Moreover, a phosphoramidon-sensitive mechanism plays a role in the regulation of the response to substance P.

Trans‐sacral (Kraske) approach for gastrointestinal stromal tumour of the lower rectum: old procedure for a new disease

Gastrointestinal stromal tumours (GISTs) of the lower rectum are rare cancers from mesenchymatous origin, which are characterized by; 1) the absence of metastases in loco‐regional lymph nodes; and 2) a tendency to grow opposite to the intestinal lumen. Thus, the two preferred surgical approaches for rectal adenocarcinomas (i.e. abdominal and transanal) are inappropriate for GISTs, due to: 1) the uselessness of total mesorectal excision; and 2) to the difficulty to locate the tumour with a transanal approach. We report here a case of a large GIST of the lower rectum which was successfully treated with a posterior trans‐sacral approach. Lower rectum GISTs are good indications for the Kraske procedure, and this relatively new disease entity may contribute to the reintroduction of an old procedure into the armamentarium of 21st century colorectal surgeons.