Pierre Garneau

Outcome after Bariatric Surgery in Two Adolescents with Hypothalamic Obesity Following Treatment of Craniopharyngioma

Treatment of craniopharyngioma (CP) in childhood can lead to severe, debilitating obesity with devastating medical and psychological outcomes. Despite sustained nutritional and exercise-oriented interventions, no efficacious medical option is available for hypothalamic obesity. We describe two adolescents who developed morbid obesity and significant comorbidities following diagnosis and treatment of CP, in whom bariatric surgery was achieved, illustrating a novel approach for symptomatic hypothalamic obesity, as well as positive and negative outcomes.

A semi-automated mass spectrometric immunoassay coupled to selected reaction monitoring (MSIA-SRM) reveals novel relationships between circulating PCSK9 and metabolic phenotypes in patient cohorts.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a key regulator of circulating low density lipoprotein cholesterol (LDL-C) levels. Besides its full-length mature form, multiple variants of PCSK9 have been reported such as forms that are truncated, mutated and/or with posttranslational modifications (PTMs). Previous studies have demonstrated that most of these variants affect PCSK9s function and thereby LDL-C levels. Commercial ELISA kits are available for quantification of PCSK9, but do not allow discrimination between the various forms and PTMs of the protein. To address this issue and given the complexity and wide dynamic range of the plasma proteome, we have developed a mass spectrometric immunoassay coupled to selected reaction monitoring (MSIA-SRM) for the multiplexed quantification of several forms of circulating PCSK9 in human plasma. Our MSIA-SRM assay quantifies peptides spanning the various protein domains and the S688 phosphorylation site. The assay was applied in two distinct cohorts of obese patients and healthy pregnant women stratified by their circulating LDL-C levels. Seven PCSK9 peptides were monitored in plasma samples: one in the prodomain prior to the autocleavage site at Q152, one in the catalytic domain prior to the furin cleavage site at R218, two in the catalytic domain following R218, one in the cysteine and histidine rich domain (CHRD) and the C-terminal peptide phosphorylated at S688 and unmodified. The latter was not detectable in sufficient amounts to be quantified in human plasma. All peptides were measured with high reproducibility and with LLOQ and LOD below the clinical range. The abundance of 5 of the 6 detectable PCSK9 peptides was higher in obese patients stratified with high circulating LDL-C levels as compared to those with low LDL-C (p < 0.05). The same 5 peptides showed good and statistically significant correlations with LDL-C levels (0.55 < r < 0.65; 0.0002 ⩽ p ⩽ 0.002), but not the S688 phosphorylated peptide. However, this phosphopeptide was significantly correlated with insulin resistance (r = 0.48; p = 0.04). In the pregnant women cohort, none of the peptides were associated to LDL-C levels. However, the 6 detectable PCSK9 peptides, but not PCSK9 measured by ELISA, were significantly correlated with serum triglyceride levels in this cohort. Our results also suggest that PCSK9 circulates with S688 phosphorylated at high stoichiometry. In summary, we have developed and applied a robust and sensitive MSIA-SRM assay for the absolute quantification of all PCSK9 domains and a PTM in human plasma. This assay revealed novel relationships between PCSK9 and metabolic phenotypes, as compared to classical ELISA assays.

Evolution of endoscopic treatment of sleeve gastrectomy leaks: from partially covered to long, fully covered stents

BACKGROUND Laparoscopic sleeve gastrectomy (SG) has become a widely accepted option in the treatment of morbid obesity. Gastric leaks after SG occur in .9%-2.2% of the patients, mostly at the gastroesophageal junction. The current treatment algorithm includes drainage, antibiotics, nutritional support, and endoluminal control. OBJECTIVES Our hypothesis is that long, fully covered stents represent a safe, effective solution for SG leaks. SETTING University hospital. METHODS A retrospective analysis of our prospectively collected bariatric database was performed between June 2014 and May 2016. We included all patients treated for leaks after SG. Endoscopic treatment included partially covered metallic stent (Wallstent, Boston Scientific, Galway, Ireland), fully covered stent (Mega stent, Taewoong Medical Industries, Gyeonggi-do, South Korea), over-the-scope clip (Ovesco Endoscopy, Tubingen, Germany), and internal pigtail drainage. RESULTS A total of 872 SGs were performed. Overall, 10 of 872 patients (1.1%) developed a gastric leak. One patient was an outside referral. The 11 patients underwent endoscopic treatment accompanied by either percutaneous or laparoscopic abscess drainage. Endoscopic fistula closure at the gastroesophageal junction was achieved in 10 of 11 cases and the average time for closure was 9.9 (range: 4-24) weeks. One patient developed a second leak in the antrum, treated by subtotal gastrectomy. Overall, treatment with Wallstent failed in 3 of 5 patients, and these patients were eventually successfully treated with a Mega stent. The initial use of long, fully covered stents was successful in 5 of 6 cases. CONCLUSION Long, fully covered stents appear to be a good alternative to traditional stents either as primary treatment or after failure of other endoscopic treatments.

Long-term outcome after laparoscopic sleeve gastrectomy in patients over 65 years old: a retrospective analysis

BACKGROUND Bariatric surgery has been proven to be a safe and effective treatment for obesity with BMI (body mass index) reduction, and resolution or lowering of obesity-related co-morbidities. The relative age limit for bariatric surgery has gradually been increased to 60 years of age and above. OBJECTIVES The aim of this study was to assess the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) performed in older patients (≥65 years old). SETTING University hospital. METHODS Between May 1, 2007 and November 30, 2013, 30 consecutive patients≥65 years old were included in this retrospective study of our prospectively collected bariatric database. RESULTS A total of 27 (90%) primary LSG and 3 revisional LSG (10%) were performed. Mean patient age was 67.2 (range: 65-74) years, and mean preoperative BMI (±standard deviation [SD]) was 44.1±5.6 kg/m2. Thirty-day morbidity included 3 cases of self-limiting nausea and vomiting and 1 case of gastric sleeve stenosis necessitating conversion to gastric bypass. No mortality reported. The overall mean percentage of excess weight loss (±SD) and percentage of total weight loss (±SD) at 12 months were 53.8±19.8 and 23.9±8.4; 52.9±21.8 and 24±9.9 at 36 months, respectively. No patients were lost to follow-up but 5 were excluded because they underwent revisions. Age-adjusted mixed model analyses revealed that baseline BMI (P = .018), BMI>45 kg/m2 (P = .001), and having diabetes (P = .030) were associated with excess weight loss<50% across follow-up. CONCLUSION LSG seems to be effective and safe for patients≥65 years old. Obesity related co-morbidities have improved across follow-up. BMI>45 kg/m2 and diabetes is associated with insufficient weight loss or weight regain.

Laparoscopic Sleeve Gastrectomy: A Radiological Guide to Common Postsurgical Failure

Laparoscopic sleeve gastrectomy is one of the most common bariatric procedures worldwide. It has recently gained in popularity because of a low complication rate, satisfactory resolution of comorbidities, and excellent weight loss outcome. This article reviews the surgical technique, expected postsurgical imaging appearance, and imaging findings of common complications after laparoscopic sleeve gastrectomy. Understanding of the surgical technique of laparoscopic sleeve gastrectomy and of the normal postsurgical anatomy allows accurate interpretation of imaging findings in cases of insufficient weight loss, weight regain, and postsurgical complications.

Extracorporeal membrane oxygenation in pheochromocytoma-induced cardiogenic shock:

Extracorporeal membrane oxygenation has been extensively used for cardiopulmonary support in cardiogenic shock. However, its clinical value in the management of pheochromocytoma crisis remains unclear. We report a rare case of life-threatening cardiogenic shock managed with peripheral venoarterial extracorporeal membrane oxygenation combined with endovascular left ventricular venting, in a 40-year-old female patient, in the setting of unknown adrenal pheochromocytoma. We highlight the life-saving role of extracorporeal membrane oxygenation in undiagnosed endocrine emergencies, allowing cardiac and end-organ recovery, and giving time for accurate diagnosis and specific treatment in such unusual situations.