Risk factors of perioperative morbimortality after laparoscopic sleeve gastrectomy: a club coelio multicenter study.

OBJECTIVES: Postoperative complications after Laparoscopic sleeve gastrectomy (LSG) can dramatically compromise patient's outcome. The aim of this study is to analyze the per- and postoperative short-term outcomes after LSG and to assess predictive risk factors of complications. METHODS: The study group consisted of 790 patients (610 women and 180 men) who underwent LSG In 2014. All interventions were performed by 18 experienced surgeons members of the Club Coelio. Data about preoperative work-up, surgical techniques, 30-days postoperative morbidity and mortality were collected. Endpoints were perioperative morbidity and mortality and assessment of potential risk factors for complications. RESULTS: Mean age and body mass index were respectively 39 years and 41.5kg/m2. Ninety-one patients (11.5%) had previous bariatric surgery. Morbidity rate was 4.7% (37/790) including 16 leaks (2.0%) and 9 bleedings (1.1%) and no deaths. Risk factors for leak were: previous adjustable banding (p = .0051), with no difference between removal of the banding and LSG in 1 or 2 steps, and type of endostapler (p = .0129). CONCLUSIONS: Leakage after Sleeve was rare but still observed even in experienced hands. The leak rate is particularly high when LSG is performed after adjustable gastric banding removal.

[Aberrant pancreas with a double intestinal location]. / Pancréas aberrant à double localisation intestinale. A propos d'un cas.

The authors report one exceptional case of aberrant pancreas with a double intestinal location (jejunum and Meckel's diverticulum) in a thirty-year-old patient. Digestive haemorrhage and the abdominal colic were the revealing clinical signs. The enteroscopy guided by the enteroscanner, was the indicated complementary investigation for the preoperative diagnosis. The research of other locations during the operation should be systematic.

[3H]spiperone binding, dopamine and HVA concentrations in Parkinson's disease and supranuclear palsy.

The density of D2-type dopamine receptors, measured by the binding of [3H]spiperone was normal in the substantia nigra, caudate nucleus and nucleus accumbens of Parkinsonian subjects and above control levels in the putamen, in spite of massive lesions of the dopaminergic neurons. Dopamine levels were reduced in the putamen, caudate nucleus, and nucleus accumbens by 97, 85 and 68%, respectively and by 78 and 93% in the pars compacta and pars reticulata of the substantia nigra. HVA levels were much less affected suggesting that increased activity of the remaining dopaminergic neurons compensated to some extent for the lesions. Neuroleptic treatment and the presence of dementia in the Parkinsonian subjects affected [3H]spiperone binding and dopamine concentrations. Dopamine and HVA levels in the striatum of subjects with supranuclear palsy indicate that the nigrostriatal system was lesioned to the same degree in this disease as in idiopathic Parkinsonism, but spiperone binding was reduced by half in all the structures studies.

[3H]spiperone binding in the nigrostriatal system in human brain.

The characteristics of [3H]spiperone binding in human brain were compared in three areas of the nigrostriatal pathway: areas containing the nerve terminals (caudate nucleus, putamen and pallidum); the area containing the cell bodies (substantia nigra pars compacta); the area containing the dendrites (pars reticulata). The affinity constants were calculated from saturation binding curves and from the kinetics of association and dissociation. The pharmacological profiles of the receptors was also established by displacement studies. The affinity constants and pharmacological profiles were similar in the striatum and the substantia nigra, although the latter contained a much smaller number of sites. In the substantia nigra, however, curved Scatchard plots were obtained, indicating that a second lower affinity site binding [3H]spiperone was also present. A considerable proportion (50%) of [3H]spiperone binding to nigral membranes could be displaced by the serotonin antagonist cinanserine , compared to the striatum (20%). The effect of post-mortem conditions on binding levels was studied in the rat. A loss of 20% occurred during the first hours after death, but was stable by 6 h until at least 24 h.

Is emergency aorto-superior mesenteric artery by-pass worthwhile?

Out of 9 superior mesenteric artery (SMA) revascularizations made in emergency, only an early direct aortic reimplantation was successful. The other cases were bypasses and their failures were due either to shock at revascularization (2 cases), or to thrombosis of a by-pass (4 cases), or to persistent ischemic lesions (2 cases). It is suggested: (1) that late mesenteric revascularization should be excluded and let place to extensive bowel resection, (2) that, in emergency, direct SMA aortic reimplantation is preferable to aorto-SMA by-pass.

[Carney's triad: a new case associated with adrenal cortex adenoma]. / Triade de Carney: un nouveau cas associé à un adénome cortico-surrénalien.

Carney's triad is a combination of at least 2 of 3 tumor sites: multiple gastric leiomyoblastoma, pulmonary chondroma and paraganglioma, most often extra-adrenal and secreting. Thirty-three cases have been published; we report a new case in a 20 year-old woman, with multiple gastric leiomyoblastomas, liver metastasis, and bilateral pulmonary chondroma. The research of paraganglioma, in regard to Carney's disease, led to the discovery of corticoadrenal adenoma.

[Acute intestinal ischemia from arterial thrombosis. Value of emergency arteriography and revascularization]. / Ischémie intestinale aiguë par thrombose artérielle. Valeur de l'artériographie et de la revascularisation en urgence.

A 77 year old woman undergoing surgery for acute digestive arterial thrombosis, was successfully revascularized without intestinal resection. Early diagnosis is difficult and is based upon evaluation of past history and an arteriography when there is the slightest doubt. Apart from when necrosis is already developed, revascularization by aorto-superior mesentric by-pass using an autologus saphenous vein and a routine "second look" to assess intestinal viability is the best therapeutic approach.

[Nonatheromatous degenerative aneurysm of the popliteal artery in a young adult female]. / Anévrisme dégénératif non athéromateux de l'artère poplitée de l'adulte jeune.

A degenerative non atheromatous popliteal aneurysm was observed in a 32 year old woman. At microscopical examination of the aneurysmal shell, the internal elastic-lamina and the muscular fibers of the media appeared to be replaced by a thick acellular collagen layer. No other arterial abnormality was found on a complete arteriography and the etiological screening failed. Therefore the aneurysm was classified as an arterial dysplasia. As far as we know, only two similar cases were previously reported in the literature. The true nature of these lesions remain unknown.

[Laparoscopic cure of gastroesophageal reflux disease. Results of a multicenter trial]. / Cure de reflux gastro-oesophagien par coelioscopie. Résultats d'une étude multicentrique.

OBJECTIVES: The aim of our trial was to assess preoperative assessment and short-term results of laparoscopic cure of gastroesophageal disease performed by digestive surgeons not specialized in this disease. METHODS: 335 consecutive cures were performed by 11 surgeons. RESULTS: 29% of patients had pH-metry, 52% had manometry. The procedure was: Nissen-Rossetti in 66% of cases, Toupet in 17%, and Nissen in 16% of cases. The conversion rate was 13%. The intraoperative complication rate was 3.28% and 2.08% of patients had a reoperation. One patient died. 5% of patients had dysphagia more than three months after the operation. CONCLUSION: Our results show an absence of consensus concerning preoperative assessment. They suggest that careful intraoperative management, with a high conversion rate, reflecting our initial experience, allows similar results to those of teams specialized in laparoscopic surgery and better than laparotomy series.

[Incapacitating dysphagia and paracardiac gastric diverticulum]. / Dysphagie invalidante et diverticule gastrique paracardial.

We report a new case of gastric diverticulum, unusual by the severity of the dysphagia and weight loss. Relief of symptoms was obtained only after surgical resection.

[Crohn disease: results of a series of 42 intestinal resections]. / Maladie de Crohn: résultats d'une série de quarante-deux résections intestinales.

Forty-two patients underwent a resection for acute or chronic complications of Crohn's disease during the years 1983-1987. The colon was involved in 38% (16 patients), the small bowel in 31% (13 patients) and the ileocaecal region in 31%. In small bowel disease, the indication for operation was either an intestinal obstruction or an internal abscess. In colonic locations, poor response to medical therapy was the indication for operation in 10 patients (63%), and an acute complication in the remaining cases. The operations performed were always "radical resections": 13 resections of small bowel, 13 ileocaecal resections, 7 ileocolectomies with ileosigmoidostomies, 6 ileocolectomies with ileorectostomies, 2 left side hemicolectomies with colorectostomies and one total coloproctectomy. There was no operative mortality. A post-operative complication occurred in two patients (4.8%). The recurrence rate was 12% after 30 months average follow up in the 34 patients with only one operation for Crohn's disease. There was no second recurrence in the 8 patients operated for a first recurrence. The factors affecting recurrence after resection were: a short pre-operative time interval since first clinical symptoms: 4.6 years versus 5.3 years without recurrence (p less than 0.01); the colonic location of the Crohn's disease (p less than 0.02). Colonic location rate of the disease was found to be higher in this study as compared to others. Since "radical resection" fails to cure all patients, surgery should be restricted to acute on chronic complications.

[Infrahepatic hematoma secondary to gangrenous cholelithiasic hemocholecyst treated with antivitamins K]. / Hématome sous-hépatique pour hémocholécyste lithiasique gangrèné sous antivitamines K.

Acute haemocholecyst is a rare disorder but often reported in patients with gallstones. Rupture of the gallbladder causing hypovolaemic shock secondary to massive intraperitoneal bleeding has been reported in about fifty patients to date. We report a new case of haemocholecyst with rupture of the gallbladder in a patient with gallstones treated by anticoagulant therapy. This case is unusual in terms of the nature of the gallbladder disease: massive gangrene with complicating hemorrhage and destruction of deficient regions of the wall of the gallbladder induced an infrahepatic haematoma without hypovolemic shock, in contrast with the massive intraperitoneal hemorrhage reported in other cases.

[Treatment of pancreatic pseudocysts by laparoscopic cystogastrostomy]. / Traitement des pseudokystes du pancréas par kystograstostomie laparoscopique.

AIM: To evaluate the clinical results of laparoscopic cystogastrostomy and to determine the potential advantages of this new therapeutic option. PATIENTS AND METHODS: This study concerned 12 patients presenting with pancreatic pseudocyst and operated on by laparoscopic cystogastrostomy between 1997 and 2002. There were five men and seven women with a median age of 46 years (range: 30-72). In ten patients, the pseudocyst developed after acute pancreatitis and the median delay between the acute onset and surgery was 7 months (range: 2-24). In two patients, the pseudocyst was associated with chronic pancreatitis. All the patients had a single cyst bulging into the posterior wall of the stomach and the median cyst diameter was 9 cm (range: 5-14). RESULTS: Endoluminal gastric laparoscopy was used in six patients and intraperitoneal transgastric laparoscopy in six patients. Conversion to open surgery was required in one patient because the cyst could not be correctly localised by laparoscopy. The median size of the cystogastrostomy was 3 cm (range: 2-5). In eight patients, necrotic debris were still present within the cyst. The median operative time was 90 min (range: 60-140) and the median postoperative hospital stay was 6 days (range: 4-24). No mortality was recorded and postoperative morbidity was limited to one haematoma of the rectus sheath on a port site. One patient was readmitted on the 20th postoperative day because of cyst infection due to partial closure of the cystogastrostomy and was treated by endoscopic placement of a stent. One patient was lost for follow-up 2 months after surgery. With a median clinical and radiological follow-up of 12 months (range: 6-36), no recurrence of pancreatic pseudocyst was observed. CONCLUSIONS: In this series, laparoscopic cystogastrostomy is associated with a low postoperative morbidity and an effective permanent result. Laparoscopy has two main advantages: an excellent control of haemostasis and the creation of a wide communication with debridement of the cyst contents thus minimizing the risk of infection or recurrence of the pseudocyst.

[The superior mesenteric artery syndrome. Apropos of a case and review of the literature]. / Le syndrome de la pince mésentérique. A propos d'une observation et revue de la littérature.

During laparotomy for an appendicular peritonitis, the authors found an acute mesenteric artery syndrome. Conservative treatment consisted of mobilisation of the 4th part of the duodenum with section of the suspensory muscle of Treitz, but this was not sufficient to cure the patient. Two weeks later the patient completely recovered after a duodenojejunal anastomosis. A review of the literature confirmed that surgical treatment for scoliosis and anorexia nervosa play an important role in the aetiology of this disease.

[Digestive hemorrhage caused by rupture of esophageal varices. Analysis of 47 emergency surgeries]. / Hémorragie digestive par rupture de varices oesophagiennes. Analyse de quarante-sept interventions en urgence.

Between 1 January 1984 and 31 December 1986, 47 patients out of a total of 228 patients admitted to hospital with endoscopy-proven bleeding esophageal varices, underwent an emergency operation. The indications were massive hemorrhage in 29 patients, and rebleeding early after a first serious episode in 18 patients. Four patients underwent early reoperation for recurrent variceal bleeding. Thirty-seven porto-caval shunts, 10 esophageal transections, 3 proximal gastric resections and 1 exploratory laparotomy were performed. The early results were satisfactory in 53.2% of the patients; operative morbidity and mortality were 19.1% and 27.7% respectively. Four patients died from gastric variceal bleeding soon after esophageal transection. Operative mortality was greater when the patient was Child C or operated for massive hemorrhage. Survivors were followed for at least 12 months. Two patients died from shunt occlusion and recurrent variceal bleeding. No severe encephalopathy was reported. Analysis of the results suggest that porto-caval shunt is indicated in Child A or B patients, particularly with recurrent variceal bleeding soon after a first episode controlled medically.

[Late revascularization of the renal artery: what are the prognostic criteria?]. / Revascularisation tardive de l'artère rénale: Quels critères pronostiques?

Two patients with non functioning silent kidney on excretory urography and renal artery occlusion on angiography, underwent renal artery revascularization without severe hypertension or renal failure. Angiographic appearance of collateral circulation, histologic evidence of intact viable glomeruli and a normal sized kidney are necessary for successful results. Renal blood flow was restored in the two patients but one had slight return of function and the other patient showed no evidence of improvement. Both patients presented criteria for revascularization. The first case was a minor success on the renal scintigraphy. The return of renal function did not occur in the second case because of preexisting renal pathology. We therefore recommend histologic examination before every renal artery revascularization for chronic occlusion.

[Cholecystectomy by celioscopy. Experience in two Upper Normandy hospital units. Apropos of 178 procedures]. / La cholécystectomie par coelioscopie. Expérience de deux services hauts normands. A propos de 178 procédures.

Laparoscopic cholecystectomy (LC) emerges as an effective alternative to classical cholecystectomy, but its safety, benefits and indications still need to be clarified. From September 1989 to March 1991, 178 LC were performed by 8 surgeons in 2 hospitals, on 142 women and 36 men with a mean age of 48.2 years. The gall bladder wall was thin in 160 cases and thick in 18 cases (with 6 cases acute cholecystitis). We observed no deaths, 147 simple procedures with a hospital stay and drug requirement lower than with the usual cholecystectomy via laparotomy. But in 21 cases, the procedure needed a laparotomy, and in 10 cases complications occurred, requiring laparotomy in 6 cases. Our results suggest: a) LC is an improvement in the treatment of uncomplicated gallstones; b) a trained surgeon and extreme caution are required in complicated cholelithiasis; c) classical cholecystectomy is still useful in many circumstances.

[Leptospirosis caused by Leptospira icterohaemorrhagiae of the pseudo-surgical type: a case]. / Leptospirose à leptospira ictero-hemorrhagiae à forme pseudo-chirurgicale: une observation.

The authors report a case of fatal leptospirosis due to Leptospira icterohaemorrhagiae revealed by typical signs of acute cholecystitis and associated with pancreatitis in a 73 year old patient presenting with gallstones. The initial clinical findings were highly suggestive of severe but typical cholecystitis and the final diagnosis was only considered when the patient's condition worsened despite surgery, with increasing obstructive jaundice and multiple organ failure. Pancreatitis was an autopsy finding. Misleading, especially gastrointestinal symptoms are frequent in leptospirosis. Hence an early diagnosis is an essential condition for a successful antibiotic management in severe cases of leptospirosis. This possibility should be considered whenever a patient presents with infectious obstructive jaundice. The patient has to be questioned concerning possible contact with contaminated animals and, when in doubt, the presence of specific antibodies should be investigated.

[Value of appendectomy by celioscopy: apropos of a series of 73 cases]. / Intérêt de l'appendicectomie par coelioscopie: à propos d'une série de 73 cas.

The practice of coelioscopic approach in acute appendicitis is still very much debated. A study of the results of 73 patients carried out over two and half years leads one to conclude to the interest of this technique also for the treatment of appendicular peritonitis. Full exploration of the abdominal cavity, easy discovery of ectopic appendix, treatment of associated lesions, extended peritoneal washing, are the observed advantages together with reduced length of hospitalisation and few post-operative complications, in particular parietals problems and obstructions at long term. The experience of the surgeon becomes of prime importance to reduce operating time, frequency of open-surgery converting and complications.

[Isolated aneurysm of the common hepatic artery. Apropos of a case report]. / Anévrysme isolé de l'artère hépatique commune. A propos d'une observation.

A case is reported of an isolated aneurysm of the common hepatic artery revealed by pain in liver region. The etiology is mainly dominated by atheroma and media dysplasia. Detection is currently during investigation of a pain syndrome or jaundice and no longer after rupture of aneurysm. Ultrasound imaging value is emphasized and angiography provides valuable data. Surgical treatment and particularly the indication for hepatic revascularization are discussed as a function of anamnestic and angiographic arguments and intraoperative findings.