Pauline Jouët

Can laparoscopy reduce hospital stay in the treatment of crohn's disease?

PURPOSE: The aim of this article was to investigate the safety, outcome, length of stay, and cost of hospital admission in patients with Crohns disease who underwent laparoscopy compared with open surgery. METHODS: Among 51 consecutive patients with inflammatory bowel disease (1996–2000), 46 with Crohns disease were included in this nonrandomized prospective study. Of these, 20 patients underwent laparoscopic surgery and 26 underwent open surgery. Data collected included the following information: age, gender, body mass index, diagnosis, duration of disease, preoperative medical treatment, previous abdominal surgery, present indication for surgery, and procedure performed (comparability measures), as well as conversion to open surgery, operating time, time to resolution of ileus, morbidity, duration of hospital stay, and cost of hospital admission (outcome measures). RESULTS: There was no significant difference with respect to comparability measures between the laparoscopic and the open-surgery groups. There was no mortality. There was no intraoperative complication in either group and no conversion in the laparoscopic group. Operating time was significantly longer in the laparoscopic group (302 minutes)vs. the open group (244.7 minutes) (P<0.05), but this difference disappeared when data were adjusted for the extra time required to perform the laparoscopic hand-sewn anastomoses (288.2 minutesvs. 244.7 minutes). Bowel function returned more quickly in the laparoscopic groupvs. the open group in terms of passage of flatus (3.7vs. 4.7 days) (P<0.05) and resumption of oral intake (4.2vs. 6.3 day) (P<0.01). There were significantly fewer postoperative complications in the laparoscopic group (9.5 percent)vs. the open group (18.5 percent) (P<0.05); the length of stay was significantly shorter in the laparoscopic group (8.3 days)vs. the open group (13.2 days) (P<0.01); and the cost of hospital admission was significantly lower in the laparoscopic group (

Gastroesophageal reflux in patients with morbid obesity: a role of obstructive sleep apnea syndrome?

6106, United States dollars)vs. the open group (

Predictive Factors of Weight Loss 1 Year after Laparoscopic Gastric Bypass in Obese Patients

9829, United States dollars) (P<0.05). CONCLUSION: There is a reduction in the postoperative ileus, length of stay, cost of hospital admission, and postoperative complication rate in the laparoscopic group. Laparoscopic surgery for Crohns disease is safe, and it is potentially more cost-effective than traditional open surgery.

Small Intestinal Bacterial Overgrowth in Patients with Morbid Obesity

BackgroundObesity is a risk factor for gastroesophageal reflux disease (GERD) and for obstructive sleep apnea (OSA). Our aim was to evaluate in morbidly obese patients the prevalence of OSA and GERD and their possible relationship.MethodsMorbidly obese patients [body mass index (BMI) >40 or >35xa0kg/m2 in association with comorbidities] selected for bariatric surgery were prospectively included. Every patient underwent a 24-h pH monitoring, esophageal manometry, and nocturnal polysomnographic recording.ResultsSixty-eight patients [59 women and 9 men, age 39.1u2009±u200911.1xa0years; BMI 46.5u2009±u20096.4xa0kg/m2 (meanu2009±u2009SD)] were included. Fifty-six percent of patients had an abnormal Demester score, 44% had abnormal time spent at pHxa0<4, and 80.9% had OSA [apnea hypopnea index (AHI) >10] and 39.7% had both conditions. The lower esophageal sphincter (LES) pressure was lower in patients with GERD (11.6u2009±u20093.4 vs 13.4u2009±u20093.6xa0mm Hg, respectively; Pu2009=u20090.039). There was a relationship between AHI and BMI (ru2009=u20090.337; Pu2009=u20090.005). Patients with OSA were older (40.5u2009±u200910.9 vs 33.5u2009±u200910.4xa0years; Pu2009=u20090.039). GERD tended to be more frequent in patients with OSA (49.1% vs 23.1%, respectively; Pu2009=u20090.089). There was no significant relationship between pH-metric data and AHI in either the 24-h total recording time or the nocturnal recording time. In multivariate analysis, GERD was significantly associated with a low LES pressure (Pu2009=u20090.031) and with OSA (Pu2009=u20090.045) but not with gender, age, and BMI.ConclusionIn this population of morbidly obese patients, OSA and GERD were frequent, associated in about 40% of patients. GERD was significantly associated with LES hypotonia and OSA independently of BMI.

Syndrome fissuraire d'un pseudoanévrisme de l'artère gastroduodénale au contact d'un faux-kyste pancréatique : une complication rare mais grave de la pancréatite chronique

BackgroundSubstantial weight loss is achieved in majority of severely obese subjects undergoing laparoscopic gastric bypass (LGBP) but some fail to obtain expected results. Our aim was to identify preoperative factors that could influence weight loss (WL) 1xa0year after LGBP.MethodsWe studied the predictive value of clinical, biological, and dietary preoperative factors on weight loss in obese patients referred for LGBP. WL was assessed according to mean absolute weight loss (AWL) and mean percent excess weight loss (%EWL) 1xa0year after LGBP.ResultsOne hundred twenty-three subjects were included (112 women, age 42u2009±u200910xa0years; weight 127u2009±u200923xa0kg; BMI 47u2009±u20098xa0kg/m2). Mean AWL was 39.4u2009±u200910.5xa0kg at 1xa0year, corresponding to a mean %EWL of 70.5u2009±u200921.2%. AWL was positively correlated with initial weight, BMI, and energy intake and negatively with age, female sex, and treatment for hypertension and diabetes. %EWL was negatively correlated with initial weight, BMI, and positively correlated with triglycerides and ferritinemia. In multivariate analysis, %EWL was negatively correlated only with initial BMI (pu2009<u20090.001). AWL was positively correlated with initial BMI and male sex (both pu2009<u20090.001), and negatively correlated with protein intake (pu2009=u20090.039) and treatment for diabetes (pu2009=u20090.021), but not with biomarkers of diabetes and insulin resistance.ConclusionInitial BMI appears to be a strong determinant of individual WL, but predictive factors differ when WL was expressed as %EWL or AWL. The treatment of diabetes rather than diabetes itself appears to affect WL.

CO.79 Apport de la pH-impédancemétrie dans l’exploration du reflux chez des patients ayant une obésité morbide : données préliminaires

To the Editor, Small intestinal bacterial overgrowth (SIBO) is an increasingly recognized cause of nonspecific gastrointestinal symptoms. Abnormal small intestinal motility and gastric acid secretion are the principal predisposing factors for this condition. We read with great interest the original article by Madrid et al. [1] regarding the prevalence of SIBO in obese patients. They found in a population of 39 patients waiting for bariatric surgery (mean age 37.5 years; BMI 44.9 ± 7 kg/m) the presence of SIBO, defined by an abnormal lactulose breath test, in 41% of them. This prevalence was increased compared to the prevalence of about 20% found in other studies [2] in asymptomatic populations, and was associated with a marked increase of clustered contractions on small intestinal manometric recording. Our group has previously reported the prevalence of SIBO using a glucose breath test in a population of 146 patients waiting for bariatric surgery (mean age 40.7 ± 11.4 years; BMI 46.1 ± 6.4 kg/m) [3]. We found a significantly higher prevalence of SIBO in obese patients compared to a group of 40 healthy subjects, with 17.1% having positive glucose breath test in the obese patient group versus 2.5% in the control group (P = 0.03) [3]. The difference in the prevalence of SIBO despite similar population characteristics could be explained by the different breath tests used for the diagnosis of SIBO, i.e. using lactulose in the Madrid et al. study [1] and glucose in our study [3]. According to the Rome consensus conference about ‘‘Methodology and indications of H2-breath testing in gastrointestinal diseases’’, glucose breath testing has shown a greater diagnostic accuracy than lactulose hydrogen breath testing [4]. In their paper, Madrid et al. [1] wrote ‘‘The relationship between SIBO and fatty liver disease may be speculated by pulling together findings of two published papers’’ performed in mice. However, in our paper a liver biopsy was also available in 136 patients [3]. In multivariate analysis, we found that SIBO (P = 0.005) and the presence of a metabolic syndrome (P = 0.006) were independent factors of severe hepatic steatosis [3]. In conclusion, we totally agree about the fact that the prevalence of SIBO is increased in morbidly obese patients waiting for bariatric surgery but not as frequently as described in the paper of Madrid et al. [1]. This phenomenon is associated with a higher prevalence of severe liver steatosis. We suggest that a glucose breath test should be preferentially used for future studies.

Flore bactérienne et cirrhose.

Most pseudoaneurysms (PsA) of the peripancreatic arteries cause direct erosion of the arterial wall from pancreatic enzymes that are usually in contact with or in a pseudocyst (PC). Rupturing is a rare and serious complication (90% mortality if untreated). We report the case of a 56-year-old patient with chronic alcoholic pancreatitis who developed a cephaloisthmic PC, complicated with a PsA of the gastroduodenal artery revealed by pain and deglobulization associated with cholestasis. After a diagnostic scan, emergency selective arteriography with coil embolization was performed. Five days later, hemorrhage recurred and a cephalic duodenopancreatectomy was performed. PsA of the gastroduodenal artery occur in the first 10 years of chronic pancreatitis. They are revealed by abdominal pains and/or gastrointestinal hemorrhage or shock from rupture. A scan with arterial reconstruction provides diagnosis. Arteriography is the most sensitive technique to locate the aneurysm and its branches and to perform selective embolization with coils. The failure rate is between 0 and 23%. Surgical treatment (elective ligation of the artery or partial pancreatic excision) should be limited to when embolisation fails and/or recurrent hemorrhage.

Bronchogenic cyst of the right hemidiaphragm mimicking a hydatic cyst of the liver

Introduction Un reflux gastro-œsophagien acide pathologique est present chez environ la moitie des patients ayant une obesite morbide en attente de chirurgie bariatrique, avec cependant une mauvaise concordance entre symptomes cliniques et reflux pH-metrique [1, 2]. Notre but est d’etudier la relation entre les symptomes de reflux et l’existence de reflux acides, non acides mesures par pH-impedancemetrie. Patients et Methodes Des patients ayant une obesite morbide (IMC > 40xa0kg/m2 ou > 35xa0kg/m2 associe a une comorbidite) en attente de chirurgie bariatrique ont beneficie, de maniere prospective, d’un interrogatoire standardise a la recherche de signes digestifs et extra-digestifs du RGO, d’une endoscopie digestive haute. Les enregistrements ambulatories couples du pH et de l’impedance oesophagiens sur 24 heures (Sandhill, CO, USA) permettaient de detecter puis caracteriser les reflux acides (pHxa0 Resultats (Moyenne ± SD et mediane, IQR) : dix-sept patients (15 femmes et 2 hommes) ont ete inclus. L’âge moyen etait de 41,8xa0±xa010,1 ans, l’IMC moyen de 44,5xa0±xa05,3xa0kg/m2. Un pyrosis, des regurgitations et une toux etaient retrouves respectivement chez 23,5 % (4/17), 17,6 % (3/17) et 29,4 % (5/17) des patients. L’endoscopie retrouvait une hernie hiatale chez 47,1 % (8/17), une œsophagite dans 1 cas. Un reflux clinique defini par un pyrosis et ou des regurgitations etait retrouve chez 29,4 % (5/17) La pH-metrie des 24 h etait pathologique (% de temps passe a pH a 4,2 %) chez 7/17 patients (41 %). La sensibilite et la specificite des symptomes de reflux pour diagnostiquer un reflux pH-metrique etaient respectivement de 42,9 % (3/7) et 60 % (3/5). L’impedancemetrie retrouvait un nombre median d’episodes de reflux de 55 (36-67) dont 72 % (45-78) etaient acides, 28 % (22-55) non acides, avec 60 % (43-67) de reflux proximaux. Le temps d’exposition au reflux etait de 1,1 % (0,7-1,95), dont 0,8 % (0,45-1,55) de reflux acide et 0,3 (0,15-0,5) de reflux non acide. Pendant l’enregistrement 41 pyrosis ou regurgitation ont ete signales correspondant a un reflux acide et non acide pour 8/41 (19,5 %) et 3/41 (7,3 %). Le groupe avec reflux clinique avait une augmentation du temps moyen de clairance du bolus par rapport au groupe sans reflux clinique (13,6 s ± 3,4 s vs 9,5 sxa0±xa03,0 s, pxa0=xa00,025). Les autres parametres de l’impedancemetrie n’etaient pas statistiquement differents dans les 2 groupes. Conclusion Dans cette population de patients avec obesite morbide on confirme la mauvaise sensibilite et specificite des symptomes pour le depistage du reflux. Dans ce travail preliminaire, la pH-impedancemetrie semble utile pour etudier ces discordances et suggere un role possible de la clairance œsophagienne du bolus.