Ten-year outcomes after primary vertical sleeve gastrectomy for morbid obesity: a monocentric cohort study.

OBJECTIVE: To assess the 10-year outcomes after sleeve gastrectomy (SG). Primary end-points were the long-term weight loss and the need for conversion and one of the secondary end-points was the incidence of gastroesophageal reflux (GERD). MATERIALS AND METHODS: Between 2006 and 2008, 40 consecutive patients had a primary SG. A retrospective analysis of our database and telephone interview of patients who defaulted clinic follow-up was conducted. Success of surgery was defined as percentage of excess weight loss (%EWL) > 50% and no need for conversion. RESULTS: Thirty-four patients (85%) achieved a 10-year follow-up. There were 11 men and 23 women with a mean preoperative body mass index (BMI) of 44 ± 4 kg/m2 and a mean age of 42 ± 8 years. Optimal weight loss was reached after a follow-up of 12 months: the mean BMI was 31 ± 5 kg/m2 and %EWL 70 ± 21%. A progressive weight regain was observed over time. With a median follow-up of 11 years (range 7-12), the mean BMI and %EWL were respectively 36 ± 8 kg/m2 (p < 0.005) and 42 ± 37% (p < 0.001). With a median delay of 9 years (range 7-9), 6 patients (18%) were converted to gastric bypass because of weight regain. On total, SG was successful only in 14 patients (41%). Success rate was particularly high in patients who had a 1-year %EWL > 75%: 10/12 (83%) vs. 4/22 (17%) (p < 0.001). Those 12 patients were only characterized by a lower preoperative BMI: 41 ± 2 vs. 45 ± 4 (p < 0.002). Besides, 22 patients (65%) had long-term GERD requiring medical treatment: the incidence of de novo GERD was 41% (6/14) and of persisting GERD 80% (16/20). CONCLUSIONS: Our 10-year success rate after SG was 41% and the incidence of GERD 65%. SG should preferably be proposed to selected patients. Patients with low preoperative BMI and without preoperative symptoms of GERD appeared as the best candidates for SG.

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.

Assessment of predictive factors for recurrence in laparoscopic ventral hernia repair using a bridging technique.

AIM: To assess the long-term incidence and predictive factors for recurrence after laparoscopic ventral hernia repair using a bridging technique. METHODS: The study group consisted of 213 consecutive patients operated by laparoscopy for primary ventral (n = 158) or incisional hernia (n = 55) between 2001 and 2014. Patients had a repair without fascia closure by intra-peritoneal onlay placement of a Parietex® composite mesh centred on the defect with an overlap of at least 3 cm. Clinical outcome was assessed by a combination of office consultation, patient's electronic medical file review and telephone interview. RESULTS: There were 144 men and 69 women with a mean age of 55 ± 12 years and a BMI of 32 ± 6. With a mean follow-up of 69 ± 44 months, a recurrent hernia was noted in 16 patients (7.5%). Univariate analysis showed a statistically significant higher recurrence rate in the following conditions: incisional hernia (15%), BMI ≥ 35 (21%), defect width >4 cm (27%), defect area >20 cm2 (27%), mesh overlap <5 cm (32%) and ratio of mesh area to defect area (M/D ratio) ≤12 (48%). Multivariate logistic analysis revealed that M/D ratio was the only independent predictive factor for recurrence (coefficient -0.79, OR 0.46, p < 0.002). With a M/D ratio ≤8, between 9 and 12, between 13 and 16, and ≥17, the recurrence rate was, respectively, 70, 35, 9 and 0% (p < 0.001). CONCLUSIONS: In laparoscopic repair of ventral hernia using a bridging technique, an overlap of at least 5 cm is not all that is required to prevent hernia recurrence. The M/D ratio is the most important predictive factor for recurrence. A ratio of 13 appears as the threshold under which that technique cannot be recommended and 16 as the threshold over which the risk of recurrence is virtually nil. If a satisfactory M/D ratio cannot be achieved, other surgical repair should be proposed to the patient.

Incisional hernia after single-incision laparoscopic cholecystectomy: incidence and predictive factors.

AIM: To access the incidence and predictive factors of incisional hernia after single-incision laparoscopic cholecystectomy (SILC). METHODS: Eighty-two consecutive patients operated on for uncomplicated cholelithiasis between 2009 and 2013 were eligible for the study. Clinical outcome was assessed by a combination of case notes review, office consultation and telephone interview. Long-term incisional hernia rate was the major outcome of the study. Secondary outcome was the evaluation of predictive factors. Univariate and multivariate statistical analyses were performed using the following variables: age, gender, ASA score, BMI, risk, or comorbidity factors and surgical site infection. RESULTS: Six patients (7 %) were lost to follow-up after the 1-month office visit and excluded. The study group consisted of 16 men and 60 women with a median age of 42 years (range 18-69) and a BMI of 25 (range 19-34). Eight patients had risk or comorbidity factors, 46 were classified ASA I, and 30 ASA II. Early postoperative course was uneventful in all cases but two patients developed a superficial wound abscess after hospital discharge. With a median follow-up of 44 months (range 12-72), incisional hernia was noted in six patients (7.9 %). Multivariate logistic analysis revealed that age (OR 1.08, 95 % CI 1.00-1.16, p < 0.038) and BMI (OR 1.37, 95 % CI 1.03-1.82, p < 0.029) were independent predictive factors of developing an incisional hernia. The incidence of hernia was, respectively, 15 % in patients with an age ≥ 50 and 33 % in patients with a BMI ≥ 30. CONCLUSION: After SILC, we noted an incisional hernia rate of 8 %. To decrease the risk of developing that specific complication, SILC should only be proposed to young and non-obese patients.

Comparison between single incision and conventional laparoscopic cholecystectomy for uncomplicated cholelithiasis.

AIM: To compare surgical outcomes of patients presenting with uncomplicated cholelithiasis and operated by single incision (SILC) or by conventional laparoscopic cholecystectomy (CLC). METHODS: The series concerned 58 consecutive patients operated between October 2008 and October 2009. There were 11 men and 47 women with a mean age of 47 years and a BMI of 29. Six patients had a past surgical history with a midline incision. The main parameters analysed were duration of operation, morbidity, postoperative pain, return to normal activities and aesthetic result. One month and one year after surgery, the cosmetic result was assessed on a visual analogue scale (VAS), a score between 9 and 10 was considered as an excellent cosmetic result. RESULTS: A SILC was performed in 26 and a CLC in 32 patients. Patients in the SILC group were characterised by a lower BMI : 25 versus 32 (p <0.001) and by the absence of previous midline incision: 0/26 (0%) versus 6/32 (19%) (p <0.028). Outcomes were similar between groups except the aesthetic result. Multivariate statistical analysis revealed that the percentage of excellent cosmetic result was higher in SILC than in CLC group : respectively 73% (19/26) vs. 28% (9/32) one month postoperatively (OR : 5.3, 95% CI: 1-23, p <0.03) and 92% (22/24) versus 55% (17/31) one year postoperatively (OR : 6.9, 95% CI : 1-46, p < 0.04). CONCLUSIONS: Our study demonstrates that SILC is a feasible and safe procedure in a selected population. Compared to CLC, the only obvious benefit is a better cosmetic result that is still observed one year after surgery.

Laparoscopic repair of primary ventral hernias: a series of 118 consecutive patients.

BACKGROUND: The aim of that study is to assess the surgical outcomes after laparoscopic repair of primary ventral hernias (PVH). METHODS: The series consisted of 118 consecutive patients presenting with PVH (13 epigastric and 105 umbilical hernias) operated between 2001 and 2010 by laparoscopy. Surgical repair consisted in intraperitoneal placement of a Parietex composite mesh centred on the defect with a minimum overlapping of 3 cm. The mesh was secured to the abdominal wall with a double crown of helical tacks alone or by an association of transfascial sutures and tacks. Patients' data were recorded prospectively. All patients were checked during office visit one month and one year after surgery and thereafter periodically evaluated by phone call. RESULTS: There were 32 women and 86 men with a mean age of 53 +/- 12 years and a body mass index (BMI) of 32 +/- 5. The median width of the defect was 2 cm (range : 1-6 cm). There was no conversion to open surgery. The mean operative time was 44 +/- 18 min. and the hospital stay 2 +/- 1 days. We noted 7 (6%) postoperative complications: 6 seromas and 1 hypodermitis. One month after surgery, no umbilical skin necrosis was observed and 102 patients (84%) considered the cosmetic result as excellent. With a mean follow-up of 66 +/- 37 months, no complication related to the use of the mesh was recorded and the recurrence rate was 3% (4/118). Predictive factors of recurrence were: BMI > or = 35 (14% (4/29), p < 0.001), mesh overlapping < 5 cm (20% (3/15), p < 0.002) and mesh fixation by tacks alone (8% (4/48), p < 0.05). CONCLUSION: Laparoscopic PVH repair is associated with very low morbidity, excellent cosmetic result and a recurrence rate of 3%. Improvement in surgical repair technique with systematic use of transfascial sutures and mesh overlapping > or = 5 cm should decrease the recurrence rate especially in obese patients.

[Gallbladder metastasis from breast carcinoma: a new case report]. / Métastase vésiculaire d'un carcinome mammaire: une nouvelle observation.

The breast carcinoma metastases preferentially in the axillary lymph nodes, bones, lungs, liver and soft tissues. Gastrointestinal or bladder dissemination is very rare. We report the case of a 63-year-old female with a clinical presentation of acute cholecystitis, who underwent laparoscopic cholecystectomy in emergency. The gallbladder showed a nodule at the infundibulum, which was responsible for the gallbladder hydrops with macroscopic features of a cholangiocarcinoma. Histological examination disclosed a metastasis from a lobular breast carcinoma with positive hormone receptors, but no overexpression of the Neu oncogene. Immunohistochemistry showed positive staining for cytokeratin7 suggesting a lesion of breast origin. The absence of E-cadherin was consistent with lobular carcinoma while negative CA 19.9 excluded cholangiocarcinoma. The patient had received 15 years previously a right mastectomy with axillary dissection followed by chemotherapy and radiotherapy for breast carcinoma of ductal type labeled SBR stage III, pT3N1 M0, showing hormone receptors but absent Neu oncogene. Proofreading of the mastectomy histological slide concluded that it was a lobular rather than a ductal type carcinoma, confirming the finding of a gallbladder metastasis 15 years after the mastectomy. The patient showed no local recurrence or contralateral lesions on magnetic resonance imaging (MRI). The bone scan showed metastases in the skull, scapula, right rib cage, thoracolumbar spine and pelvis, also confirmed by MRI. A treatment with exemestane and zoledronic acid was introduced. The follow-up at 6 months showed regression of the bone lesions and absence of parenchymal new locations.

Is laparoscopic appendectomy an effective procedure?

AIM: To compare the results of open and laparoscopic appendectomy and to determine if the laparoscopic approach might be more effective for some subgroups of patients. MATERIAL AND METHODS: We retrospectively analysed the computerised data of 326 consecutive adult patients operated on for suspected appendicitis between 2001 and 2005. The series consisted of 166 men and 160 women with a mean age of 32 +/- 16 years and a mean Body Mass Index (BMI) of 24 +/- 4. There were 265 ASA I, 46 ASA II and 5 ASA III patients. According to the surgeon's preference, 176 patients had an open appendectomy (OA) and 150 a laparoscopic appendectomy (LA). RESULTS: The mean operative time and hospital stay were equivalent in the two groups : respectively 49 +/- 19 min. and 4.1 +/- 2.5 days in OA and 50 +/- 16 min. and 3.5 +/- 1.8 days in LA. However, subgroup analysis revealed that overweight (BMI > 25) patients (n = 102) and patients with ectopic appendices (n = 86) had an obvious benefit from LA. In cases of OA, operative time and hospital stay were longer in overweight patients than in normal weight patients: respectively 63 +/- 20 min. and 5.3 +/- 2.9 days versus 44 +/- 16 min. (p < 0.01) and 3.7 +/- 2.2 days (p < 0.01). On the contrary, no difference was observed in the LA group. Operative time and hospital stay were also longer in patients with ectopic appendices submitted to OA than in patients with an appendix in the normal position: respectively 60 +/- 18 min. and 4.7 +/- 2.7 days versus 45 +/- 18 min. (p < 0.01) and 3.9 +/- 2.4 days (p < 0.01). Again, such a difference was not observed in cases of LA. We noted no mortality, but 24 patients (7%) developed an abdominal complication : 18 wound infections and 6 intra-abdominal abscesses. Wound infections were more common in the OA than in the LA group : 7.3% (13/176) versus 3.3% (5/150) (p = 0.1). In the LA group, 4 wound infections were observed in our early experience, at a time where no endoscopic bag was used for the removal of the appendix. The rate of intra-abdominal abscesses was similar: 1.7% (3/176) in the OA group and 2% (3/150) in the LA group. CONCLUSIONS: LA is an effective procedure with a reduced risk of developing wound infection. The laparoscopic approach is particularly effective for overweight patients and/or patients with ectopic appendices as far as shortening the operative time and hospital stay is concerned.

Comparative study of the lipolytic potencies of pituitary-derived and biosynthetic human growth hormone in hypopituitary children.

Whether stimulation of lipolysis is an intrinsic property of the human growth hormone (hGH) molecule or is due to contaminants of pituitary origin is controversial. We compared the rises in plasma FFA levels 4 h after an im injection of 0.2 U/kg of either pituitary hGH (n = 5) or biosynthetic methionyl hGH (n = 32) to hypopituitary patients. In each patient, plasma FFA levels also were measured during a similar period of fasting alone, without hGH injection. Plasma FFA levels rose between 0800 and 1230 h in both subgroups of patients during fasting alone. Injection of either pituitary or biosynthetic methionyl hGH led to a greater increase in plasma FFA than that induced by fasting alone, and the percent increases over baseline plasma FFA levels induced by either pituitary or synthetic hGH were similar. Triceps skinfold thickness before and after 3 months of treatment with biosynthetic hGH in 20 patients diminished by a mean of 2.5 mm, a decrease similar to that reported with pituitary hGH. We conclude that the acute and chronic lipolytic effect of hGH in man is an intrinsic property of the hGH molecule.

Sex hormone-binding protein in hyperthyroxinemic patients: a discriminator for thyroid status in thyroid hormone resistance and familial dysalbuminemic hyperthyroxinemia.

Sex hormone-binding globulin (SHBG) levels in serum are affected by thyroid status; hyperthyroidism is associated with high SHBG levels, whereas hypothyroid patients have low or normal SHBG levels. This study was undertaken to test the usefulness of SHBG determinations to define the thyroid status in two hyperthyroxinemic states: thyroid hormone resistance (THR) and familial dysalbuminemic hyperthyroxinemia (FDH). Serum SHBG levels were determined in 193 patients and 26 normal subjects using an IRMA-type RIA. In the control group, the mean values in women (58.9 nmol/liter) and men (32.7 nmol/liter) were significantly different (P less than 0.001). In adult subjects with THR, SHBG levels were within the normal range, with mean values of 54.8 nmol/liter (range, 28.7-82.5 nmol/liter) in women and 18 and 20 nmol/liter in two men. In FDH subjects, the mean SHBG levels did not differ from the normal values; they averaged 60.7 nmol/liter in women and 42.3 nmol/liter in men. From these data we conclude that in THR and FDH, free T4 levels elicit an appropriate hepatic response corresponding to the euthyroid status of these subjects. SHBG determination may, therefore, serve as an in vitro test for end-organ sensitivity to thyroid hormones.

Growth-promoting effect of growth hormone and low dose ethinyl estradiol in girls with Turner's syndrome.

Forty patients with Turner's syndrome, aged 5.0-16.6 yr, were randomly allocated to receive daily sc injections of recombinant human GH (hGH) at a dose of 1 IU/kg.week alone (group I) or in combination with 25 ng/kg.day ethinyl estradiol (E2; group II). The mean pretreatment height velocity was 3.8 cm/yr for both groups. During the first year of treatment height velocity increased significantly (P less than 0.001) in both groups, to 7.5 +/- 1.3 and 8.1 +/- 1.6 cm/yr, respectively. The difference between the two groups was not significant. The mean (+/- SD) height velocity expressed as the SD score for chronological age (Turner references) was 0.0 +/- 1.2 for group I and 0.2 +/- 1.4 for group II and increased significantly (P less than 0.001) during the first year of treatment to +4.3 +/- 1.1 in group I and +5.4 +/- 1.2 in group II. The difference between both groups was statistically significant (P less than 0.01). Height SD score for chronological age (Turner references) increased from -0.2 +/- 0.9 to +0.6 +/- 1.0 in group I and from -0.2 +/- 1.0 to +0.7 +/- 1.1 in group II. Mean bone age progressed similarly in both treatment groups (1.1 +/- 0.6 yr during 1 yr of treatment). However, bone age maturation accelerated more rapidly in younger patients. Twelve girls (three in group I and nine in group II) had minor breast development. No major adverse effects were reported. We conclude that daily sc therapy with hGH stimulates height velocity in Turner's syndrome. The beneficial effect on height velocity increment of E2 addition was small. Furthermore, even very low doses of E2 may induce breast development at an early age and accelerate bone maturation. For these reasons, the addition of E2 to hGH is not warranted in young patients with Turner's syndrome.

Pubertal growth and final height in hypopituitary boys: a minor role of bone age at onset of puberty.

Twenty-two hypopituitary boys treated with human GH were studied longitudinally before and during puberty. Eight patients entered spontaneous puberty at a mean bone age of 12.4 +/- 1.0 (+/- SD) yr. Height velocity reached a mean peak of 6.8 cm/yr during the second year of spontaneous puberty. In these patients, the mean total height gain throughout puberty was 22.8 +/- 5.2 cm, and the mean final height was 158.6 +/- 7.2 cm. Fourteen patients received testosterone enanthate (100 mg/month, im) starting at a mean bone age of 13.6 +/- 1.1 yr. Height velocity was maximal (7.5 cm/yr) during the first year of therapy. The mean final height was 162.9 +/- 5.0 cm, with a mean pubertal gain of 15.9 +/- 3.8 cm. Genital development, peak height velocity, and increase in plasma testosterone levels occurred earlier during testosterone therapy than during spontaneous puberty. In both groups of patients, there was a positive correlation between the bone age at onset of puberty and the height at onset of puberty (r = 0.65). There was also a negative correlation between bone age and total pubertal height gain (r = -0.73). This reduction in pubertal height increase was less than expected for bone age at onset of puberty, which can be explained by a decrease in bone age velocity in relation to bone age at onset of puberty (r = -0.81). Therefore, advancement in bone age at the onset of testosterone therapy did not impair final height, whereas it may increase height at onset of puberty, which is the major factor in final height. We conclude that in GH- and gonadotropin-deficient boys 1) a reduced dosage of testosterone enanthate (25 mg twice a month, im) should be used to induce pubertal development, and 2) the major criterion to decide when to give testosterone is height reached at that time regardless of bone age.

Autosomal dominant transmission of congenital thyroid hypoplasia due to loss-of-function mutation of PAX8.

Congenital hypothyroidism (CH) is a relatively frequent and potentially severe disease. It is classically subdivided into: 1) thyroid dysgenesis (TD), a defect in the organogenesis of the gland leading to hypoplastic, ectopic, or absent thyroid gland; or 2) thyroid dyshormonogenesis, a defect in one of the biochemical mechanisms responsible for thyroid hormone synthesis. Most cases of TD are sporadic, although familial occurrences have occasionally been described. Recently, several genes have been implicated in a small proportion of TD, but, in the majority of the cases, the etiology remains unknown. PAX8 is a transcription factor involved in thyroid development. So far, three loss-of-function mutations of PAX8 have been described, two in sporadic cases and one in familial thyroid hypoplasia. Here, we describe a novel mutation of PAX8 causing autosomal dominant transmission of CH with thyroid hypoplasia. The mutation consists of the substitution of a tyrosine for cysteine 57 in the paired domain of PAX8. When tested in cotransfection experiments with a thyroid peroxidasse promoter construct, the mutant allele was unable to exert its normal transactivation effect on transcription. Our results give further evidence that, contrary to the situation in knockout mice, haplo-insufficiency of PAX8 is a cause of CH in humans.

Early, discontinuous, high dose growth hormone treatment to normalize height and weight of short children born small for gestational age: results over 6 years.

Most children born small for gestational age (SGA) normalize their size through spontaneous catch-up growth within the first 2 yr after birth. Some SGA children fail to do so and maintain an abnormally short stature throughout childhood. We have previously reported that high dose GH treatment (66 or 100 microg/kg x day s.c. over 2 yr; age at start, 2-8 yr; n = 38) induces pronounced catch-up growth in short children born SGA, thereby normalizing their height and weight in childhood. Here, we report on the further prepubertal growth course of these children over the first 4 yr after withdrawal of early, high dose GH treatment. Of the 38 treated children, none developed precocious puberty, and 22 remained prepubertal. Mean age of the latter at start of GH was 4.4 yr, height was -3.7 SD score, and height after adjustment for midparental height was -2.9 SD score. Height increased by an average of 2.5 SD during the 2 yr of GH treatment and decreased by 0.4 and 0.3 SD, respectively, during the first and second year after GH withdrawal. Subsequently, when stature was not extremely short at the start (mean adjusted height SD score, -2.7; n = 13), no further GH treatment was given, and the adjusted height was stabilized around -1.0 SD score; when stature was very short at the start (mean adjusted height, -3.3 SD score; n = 9), a second course of GH treatment (66 microg/kg x day s.c.) was initiated either 2 yr (n = 5) or 3 yr (n = 4) after initial GH withdrawal. This second course was associated with renewed catch-up growth and also resulted in a mean adjusted height of -1.0 SD score. In each subgroup, the pattern of the weight course paralleled that of the height course; GH treatment was well tolerated. In conclusion, early, discontinuous, high dose GH treatment appears to be a safe and efficient option to normalize prepubertal height and weight in the majority of short SGA children. It remains to be examined whether the normalized stature will be maintained during pubertal development, either with or without further GH treatment.

Hypopituitarism and idiopathic delayed puberty: a longitudinal study in an attempt to diagnose gonadotropin deficiency before puberty.

Fifty-five hypopituitary patients (43 boys and 12 girls) treated with human GH were studied longitudinally before and during puberty, occurring either spontaneously or induced with testosterone enanthate (100 mg/month, im) in boys and ethinylestradiol (10 micrograms/day, orally) in girls. In addition, 53 boys with idiopathic delayed puberty (IDP) were studied. Gonadotropin integrated responses (IRs) during 90 min after the iv injection of 25 micrograms/m2 LRH, bone ages (BA), and plasma levels of dehydroepiandrosterone sulfate and testosterone were determined at least yearly. Prepubertal hypopituitary patients with gonadotropin deficiency were characterized by: 1) a lowered FSH IR to LRH in most boys and in all girls; 2) a low LH IR for BA; 3) adrenarche either absent or delayed BA; 4) height age close to BA; and 5) the presence of several pituitary deficiencies. In contrast, most prepubertal hypopituitary patients without gonadotropin deficiency showed: 1) a normal FSH IR to LRH; 2) a normal or intermediate (greater than or equal to 75 mIU/ml . 90 min) LH IR for BA; 3) a normal adrenarche for BA; 4) a height age below BA; and 5) isolated GH or GH plus TSH deficiencies. A significant linear correlation was found between LH IR and the logarithm of plasma testosterone. The slopes and levels were similar in controls and hypopituitary boy without gonadotropin deficiency. In IDP, the level was significantly higher. All data obtained in these patients show that the increase in plasma testosterone and the clinical onset of puberty are delayed for the observed pubertal pattern of LH responsiveness. It is concluded that the study of several clinical and biological features, especially the gonadotropin IR to LRH, are of predictive value for the diagnosis of normal or deficient gonadotropic function in prepubertal patients with IDP and hypopituitarism.

Age-related perception of stature, acceptance of therapy, and psychosocial functioning in human growth hormone-treated girls with Turner's syndrome.

This study evaluated the perception of stature, acceptance of therapy, and psychosocial functioning in relation to age at onset and time on treatment during 2 yr of GH therapy in 31 girls with Turner's syndrome grouped by age (group A: 3.7-5.8 yr, n = 9; group B: 7.2-11.8 yr, n = 13; group C: 12.5-16.4 yr, n = 9). The growth response after 2 yr was significant in the 3 groups when calculated in terms of growth norms for untreated Turner girls (mean increase in height SD score: +1.2, +1.5, and +1.1, respectively). The effect was less marked in terms of growth norms for normal girls, particularly in group B (+0.5 SD score). Height was perceived as a problem by most patients, except in the youngest girls at the start of treatment (group A) and in the majority of the adolescents after 2 yr of GH therapy (group C), without evidence of relation to growth response during therapy. The GH injections were fairly well accepted by all patients, except those younger than 6 yr. In all patients, expected adult height was unrealistic and became more realistic with age, whereas no consistent changes were observed in relation to growth response to GH therapy. The Child Behavior Checklist revealed elevated mean scores at the behavioral subscales of attention problems (group A and B), social problems, withdrawal, and anxiety-depression (most obviously in group B). No significant changes were seen during GH therapy. In group C, an elevated mean social problem score at the Youth Self Report and a low mean social self-esteem score at the Self-Esteem Inventory were observed before therapy and showed a significant improvement during 2 yr of GH treatment. These results, however, might be biased due to an increase in social desirability during therapy. We conclude that the perception of height, acceptance of GH therapy, and psychosocial functioning in girls with Turner's syndrome show important differences between age groups, with only slight changes observed during GH therapy.

High-dose growth hormone treatment of short children born small for gestational age.

The effect of GH administration was evaluated over 2 yr in 50 short, prepubertal, non-GH deficient children born small for gestational age, who had been randomly allocated to a group receiving no treatment or daily sc GH treatment at a dose of 0.2 or 0.3 IU/kg. At the start of the study, mean age was 5.2 yr, bone age was 4.0 yr, height SDS was -3.5, height velocity SDS was -0.8, weight SDS was -2.7, and body mass index SDS was -1.9. Catch-up growth was observed in none of the untreated and all of the treated children. The response to GH treatment included a near doubling of growth velocity and of weight gain and a mean height increment of more than 2 SDS. GH treatment was associated with a distinct acceleration of bone maturation. The differences between the growth responses evoked by the two GH doses were minor. The prepubertal GH-induced catch-up growth was associated with elevated serum concentrations of insulin, insulin-like growth factor-I, insulin-like growth factor binding protein-3, and osteocalcin, whereas insulin-like growth factor-II levels remained unaltered. GH treatment was well tolerated. In conclusion, high-dose GH administration over 2 yr is emerging as a potential therapy to increase the short stature that results from insufficient catch-up growth in young children born small for gestational age. The long-term impact of this approach remains to be delineated.

Noninvasive imaging of insulinomas and gastrinomas with endoscopic ultrasonography and somatostatin receptor scintigraphy.

BACKGROUND: Classic morphological techniques are of limited value for imaging endocrine duodenopancreatic tumors, and invasive procedures such as intraarterial stimulation are often used. Two noninvasive procedures, endoscopic ultrasonography (EUS) and somatostatin receptor scintigraphy (SRS), were recently described with promising results. METHODS: In this study we correlated the results of preoperative EUS (n = 34) and SRS (n = 30) with operative findings in patients with histologically proven insulinoma (n = 20) or gastrinoma (n = 21). RESULTS: The sensitivity and positive predictive value (PPV) of EUS were respectively 77% and 94% for pancreatic tumors (insulinomas and gastrinomas), 40% and 100% for duodenal gastrinomas, and 58% and 78% for metastatic lymph nodes. The sensitivity and PPV of SRS for insulinoma were 60% and 100%, respectively. In patients with gastrinoma, the sensitivity and PPV of SRS were respectively 25% and 100% for pancreatic gastrinomas, 72% and 100% for duodenal gastrinomas or periduodenal metastatic lymph nodes, and 67% and 80% for liver metastasis. In patients with multiple endocrine neoplasia, neither one of the two techniques detected all tumors. Overall sensitivity of combined EUS and SRS was 89% for insulinoma (n = 9) and 93% for gastrinoma (n = 14). CONCLUSIONS: EUS and SRS for gastrinomas and insulinomas should be considered as the initial preoperative imaging procedures and may render invasive procedures unnecessary for most patients.

Laparoscopic treatment of a gastric outlet obstruction caused by a gallstone (Bouveret's syndrome).

Duodenal impaction of a gallstone after its migration through a cholecystoduodenal fistula is an uncommon cause of gallstone ileus described as Bouveret's syndrome. Surgical treatment is recommended, but the morbidity and mortality rates are nearly 60% and 30%, respectively. To reduce these rates using improved endoluminal surgery, a laparoscopically assisted intraluminal gastric surgery could be considered. A 74 year-old woman was admitted with typical Bouveret's syndrome. An intraluminal gastric laparoscopy was performed. The large stone impacted in the first duodenum was removed through the pylorus and pulled into the stomach. After its mechanical fragmentation, the stone was extracted with a sterile retriever bag through the main trocar. In the case of Bouveret's syndrome, treatment of the duodenal obstruction is mandatory. Surgical treatment of the cholecystoduodenal fistula still is controversial. We never perform a one-stage procedure, and we reserve a biliary operation for the patient who remains symptomatic. In this way, laparoscopically assisted intraluminal gastric surgery with transpyloric extraction of the stone can be a safe and interesting approach for this type of pathology.

Growth hormone deficiency: a hidden obstetrical trauma?

Fetal presentation, mode of delivery and onset of labour were reviewed in 177 patients with documented growth hormone deficiency. Non-cephalic presentations were about ten times more frequent in this group of patients than in a control population. All children with breech position were delivered vaginally and spontaneously, suggesting a pituitary insult during vaginal delivery. 'True idiopathic' isolated growth hormone deficiency was frequently found in association with induction of labour. The data indicate that even a mild birth trauma may result in growth hormone deficiency.