Thierry Bège

An endoscopic strategy for management of anastomotic complications from bariatric surgery: a prospective study

BACKGROUND Treatment of anastomotic fistulas after bariatric surgery is difficult, and they are often associated with additional surgery, sepsis, and prolonged non-oral feeding. OBJECTIVE To assess a new, totally endoscopic strategy to manage anastomotic fistulas. DESIGN Prospective study. SETTING Tertiary-care university hospital. PATIENTS This study involved 27 consecutive patients from July 2007 to December 2009. INTERVENTION This strategy involved successive procedures for endoscopic drainage of the residual cavity, diversion of the fistula with a stent, and then closure of the residual orifice with surgical clips or sealant. MAIN OUTCOME MEASUREMENTS Technical success, mortality and morbidity, migration of the stent. RESULTS Multiple or complex fistulas were present in 16 cases (59%). Endoscopic drainage (nasal-fistula drain or necrosectomy) was used in 19 cases (70%). Diversion by a covered colorectal stent was used in 22 patients (81%). To close the residual or initial opening, wound clips and glue (cyanoacrylate) were used in 15 cases (55%). Neither mortality nor severe morbidity occurred. Migration of the stent occurred in 13 cases (59%) and was treated by replacement with either a longer stent or with 2 nested stents. The mean time until resolution of fistula was 86 days from the start of endoscopic management, with a mean of 4.4 endoscopies per patient. LIMITATIONS Moderate sample size, nonrandomized study. CONCLUSION An entirely endoscopic approach to the management of anastomosing fistulas that develop after bariatric surgery--using sequential drainage, sutures, and diversion by stents--achieved resolution of the fistulas with minimal morbidity.

Bevacizumab-Related Surgical Site Complication Despite Primary Tumor Resection in Colorectal Cancer Patients

BackgroundCombining conventional systemic chemotherapy with the angiogenesis inhibitor bevacizumab is now recommended as a first treatment for metastatic colorectal neoplasms. The risk for short-term postoperative complications related to bevacizumab has been assessed. Late postoperative complications related to bevacizumab have also been suggested by preliminary reports.MethodsWe reviewed a cohort of 142 patients with previous surgery for primary colonic or rectal tumor and without evidence of local recurrence, receiving bevacizumab for metastatic disease.ResultsFour patients experienced a late surgical site complication related to bevacizumab. Common features were rectal location, low anastomosis, and preoperative irradiation. Combining these three factors, the risk of a bevacizumab-related complication was 4 in 27 (14.8%); if previous history of postoperative leakage was reported, the risk was raised to 2 in 4. No complications occurred in colonic location or the non-irradiated patients. The mechanism of these complications could be ischemic lesion in post-irradiated tissues involving anastomoses.ConclusionWe conclude that angiogenesis inhibitors should be carefully considered for patients having low colorectal anastomosis and previous irradiation.

Hydrolytic Fate of 3/15-Acetyldeoxynivalenol in Humans: Specific Deacetylation by the Small Intestine and Liver Revealed Using in Vitro and ex Vivo Approaches

In addition to deoxynivalenol (DON), acetylated derivatives, i.e., 3-acetyl and 15-acetyldexynivalenol (or 3/15ADON), are present in cereals leading to exposure to these mycotoxins. Animal and human studies suggest that 3/15ADON are converted into DON after their ingestion through hydrolysis of the acetyl moiety, the site(s) of such deacetylation being still uncharacterized. We used in vitro and ex vivo approaches to study the deacetylation of 3/15ADON by enzymes and cells/tissues present on their way from the food matrix to the blood in humans. We found that luminal deacetylation by digestive enzymes and bacteria is limited. Using human cells, tissues and S9 fractions, we were able to demonstrate that small intestine and liver possess strong deacetylation capacity compared to colon and kidneys. Interestingly, in most cases, deacetylation was more efficient for 3ADON than 15ADON. Although we initially thought that carboxylesterases (CES) could be responsible for the deacetylation of 3/15ADON, the use of pure human CES1/2 and of CES inhibitor demonstrated that CES are not involved. Taken together, our original model system allowed us to identify the small intestine and the liver as the main site of deacetylation of ingested 3/15ADON in humans.

Laparoscopic Approach Is feasible in Crohn’s Complex Enterovisceral Fistulas: A Case-Match Review

BACKGROUND: Complex enterovisceral fistulas are internal fistulas joining a “diseased” organ to any intra-abdominal “victim” organ, with the exception of ileoileal fistulas. Few publications have addressed laparoscopic surgery for complex fistulas in Crohn’s disease. OBJECTIVE: The aim of this study was to evaluate the feasibility of such an approach. DESIGN: This study is a retrospective, case-match review. SETTINGS: This study was conducted at a tertiary academic hospital. PATIENTS: All patients who underwent a laparoscopic ileocecal resection for complex enterovisceral fistulas between January 2004 and August 2011 were included. They were matched to a control group undergoing operation for nonfistulizing Crohn’s disease according to age, sex, nutritional state, preoperative use of steroids, and type of resection performed. Matching was performed blind to the peri- and postoperative results of each patient. MAIN OUTCOME MEASURES: The 2 groups were compared in terms of operative time, conversion to open surgery, morbidity and mortality rates, and length of stay. RESULTS: Eleven patients presenting with 13 complex fistulas were included and matched with 22 controls. Group 1 contained 5 ileosigmoid fistulas (38%), 3 ileotransverse fistulas (23%), 3 ileovesical fistulas (23%), 1 colocolic fistula (8%), and 1 ileosalpingeal fistula (8%). There were no significant differences between the groups in terms of operative time (120 (range, 75–270) vs 120 (range, 50–160) minutes, p = 0.65), conversion to open surgery (9% vs 0%, p = 0.33), stoma creation (9% vs 14%, p = 1), global postoperative morbidity (18% vs 32%, p = 0.68), and major complications (Dindo III: 0% vs 9%, p = 0.54; Dindo IV: 0% vs 0%, p = 1), as well as in terms of length of stay (8 (range, 7–32) vs 9 (range, 5–17) days, p = 0.72). No patients died. LIMITATIONS: This is a retrospective review with a small sample size. CONCLUSION: A laparoscopic approach for complex fistulas is feasible in Crohn’s disease, with outcomes similar to those reported for nonfistulizing forms.

Time Course of Change in Ectopic Fat Stores After Bariatric Surgery.

More than body mass index (BMI), adiposity distribution in visceral area and in ectopic sites likely plays an important role in the obesity-related risk. Ectopic fat accumulation in the heart, the liver, and the pancreas, namely steatosis, could induce accumulation of toxic lipid intermediates

Does faecal diversion prevent morbidity after ileocecal resection for Crohn's disease? Retrospective series of 80 cases.

After ileocecal resection for Crohns disease, a temporary faecal diversion is indicated in high‐risk patients. The impact of a temporary stoma on post‐operative morbidity has been poorly assessed so far. The aim was to analyse post‐operative morbidity of temporary faecal diversion after ileocecal resection for Crohns disease.

Hollow viscus injury due to blunt trauma: A review.

Blunt abdominal trauma results in injury to the bowel and mesenteries in 3-5% of cases. The injuries are polymorphic including hematoma, seromuscular tear, perforation, and ischemia. They preferentially involve the small bowel and may result in bleeding and/or peritonitis. An urgent laparotomy is necessary if there is evidence of active bleeding or peritonitis at the initial examination, but these situations are uncommon. The main diagnostic challenge is to promptly and correctly identify lesions that require surgical repair. Diagnostic delay exceeding eight hours before surgical repair is associated with increased morbidity and probably with mortality. Because of this risk, the traditional therapeutic approach has been to operate on all patients with suspected bowel or mesenteric injury. However, this approach leads to a high rate of non-therapeutic laparotomy. A new approach of non-operative management (NOM) may be applicable to hemodynamically stable patients with no signs of perforation or peritonitis, and is being increasingly employed. This attitude has been described in several recent studies, and can be applied to nearly 40% of patients. However, there is no consensual agreement on which criteria or combination of clinical and radiological signs can insure the safety of NOM. When NOM is decided upon at the outset, very close monitoring is mandatory with repeated clinical examinations and interval computerized tomography (CT). Larger multicenter studies are needed to better define the selection criteria and modalities for NOM.

Stab wounds in emergency department

Stab wounds represent the most common cause of penetrating wounds, occurring mainly in case of aggression or suicide attempt. Clinical severity depends on the superficial or penetrating aspect of the wound, its location and damaged organs. Medical management must be known because the vital risk is involved in penetrating wounds. Hemodynamically unstable patients should be operated without delay after performing a chest X-ray and ultrasound Focus assisted sonography for trauma (FAST) to guide the surgery. In the stable patients, the general clinical examination, exploration of the wound and medical imaging detect injuries requiring surgical management. Stab penetrating wounds require close and rapid collaboration between medical teams, tailored to the institutions resources.

Risques liés au tabagisme en chirurgie générale et digestive

Peri-operative smoking history is an important risk factor, which is often under-appreciated by surgeons. In the first place, tobacco use predisposes patients to specific pathologies, which may require surgical intervention. Secondarily, smoking has been shown to increase surgical risks of mortality, morbidity and length of hospital stay. Of particular importance in general surgery is the increased risk of anastomotic leak with fistula formation, of deep infections, and of abdominal wall complications (infection and ventral hernia). If the patient can stop smoking prior to surgery, there is a concomitant decrease in post-operative complications. Surgeons should be familiar with the pharmacologic and behavioral interventions, which may help the patient with smoking cessation and should not hesitate to defer elective surgery for four to eight weeks so that the patient may have the full benefit of smoking cessation.

Towards a necessary evolution in emergency surgery

One of the peculiarities of the organization of emergency surgery in France is… that there is no specific organization! While few departments of emergency surgery exist, nearly all surgical departments that participate in this activity have neither a dedicated organization nor specialized practitioners. And yet, emergency surgery represents a major portion of activity in our discipline. Despite this high volume of emergency cases, the present-day image, dynamism and attractiveness of academic emergency surgery does not correspond with its rich history, particularly for young surgeons. It is time to recognize these difficulties and to seriously reflect on the organization and quality of care in France in the light of experience from other countries, in order to restore emergency surgery to the place it deserves.