Malignancy in bariatric surgery patients: a French multisite cohort.

BACKGROUND: Bariatric surgery is associated with decreased cancer-related mortality. An indefinite proportion of patients that undergo bariatric surgery have a history of malignancy or will develop cancer. In these patients, weight loss and oncologic evolution needed to be assessed. The aim of this study was to report the results of patients diagnosed with malignancy before and after bariatric surgery in a French multisite cohort. METHODS: We conducted a retrospective cohort study of all patients who underwent bariatric surgery in six university centers. Patients were divided in two groups: patients with a preoperative history of malignancy and patients diagnosed with malignancy during the follow-up. Both groups were compared with control groups of patients that underwent surgery during the same period. RESULTS: From 2008 to 2018, 8927 patients underwent bariatric surgery. In patients with a history of malignancy (n = 90), breast and gynecologic cancers were predominant (37.8%). Median interval between malignancy and surgery was 60 (38-118) months. After a follow-up of 24 (4-52) months, 4 patients presented with cancer recurrence. Comparative analysis demonstrated equivalent weight loss one year after surgery. In patients with postoperative malignancy (n = 32), breast and gynecologic cancers were also predominant (40.6%). Median interval between surgery and malignancy was 22 (6-109) months. In the comparative analysis, weight loss was similar at 2 years. CONCLUSIONS: History of malignancy should not be considered as an absolute contraindication for bariatric surgery. Gynecological cancer screening should be reinforced before and after surgery. The development of malignancy postoperatively does not seem to affect mid-term bariatric outcomes.

Postoperative morbidity and mortality for malignant colon obstruction: the American College of Surgeon calculator reliability.

BACKGROUND: The American College of surgical risk calculator (SRC) score has never been validated specifically for surgery in emergency. The objective was to evaluate the reliability of this calculator in patients with malignant colon obstruction. MATERIALS AND METHODS: We retrospectively have analyzed the morbidity and mortality observed in operated patients. Risk factors for postoperative morbidity and mortality were analyzed by logistic regression model. We have compared the morbidity and mortality estimated by the SRC score with that observed using the Brier Score (BS). A BS of 0 indicated perfect prediction, whereas a BS of 1 indicated the poorest prediction. RESULTS: Sixty-nine patients aged 75 y (41-93) have been operated on emergency from November 2001 to August 2015. The tumor was localized in the sigmoid in 33 cases (48%), in the splenic flexure in nine cases (13%), and in the right colon in 17 cases (25%). The surgical procedures were as follows: right colectomy with anastomosis (29%), diverting proximal iliac colostomy (23%), and subtotal colectomy with anastomosis (19%). The SRC score indicated a good predictivity for mortality (9.8% predicted versus 8.7% observed, BS = 0.058), for morbidity (33.4% versus 40.6%, BS = 0.209), and for serious morbidity (25.5% versus 17.4%, BS = 0.131). In multivariate analysis, SRC was an independent risk factor for mortality (P = 0.030 odds ratio [OR] = 1.07 [1.01-1.15]) and morbidity (P = 0.001 OR = 1.16 [1.08-1.27]). CONCLUSIONS: SRC score is a reliable tool for assessing the morbidity and mortality of obstructive colon cancer and could help with adapting the surgical gesture to the risks predicted.

Prognostic Value of Sterilized Lymph Nodes After Preoperative Chemoradiotherapy for Patients with ypN0 Rectal Cancer.

BACKGROUND: Patients with ypN0 rectal cancer who have received preoperative chemoradiotherapy can be divided into those who initially were node negative and those whose positive nodes have been sterilized by preoperative therapy. The long-term prognosis for ypN0 patients with sterilized lymph nodes (LNS) is unknown. This study aimed to assess the prognostic value of LNS after preoperative chemoradiotherapy for patients with ypN0 rectal cancer. METHODS: From January 2007 to March 2014, 206 patients with ypN0 tumors of the mid or lower rectum treated by chemoradiotherapy and radical surgery were enrolled in the study. Of these 206 patients, 49 had ypN0 tumors with LNS (LNS+ group), and 157 had ypN0 tumors without LNS (LNS- group). The patients in both groups were comparable in terms of tumor characteristics, type of chemoradiotherapy, type of surgery, R0 resection rate, and postoperative complication rate. RESULTS: The mean follow-up period was 40.5 ± 27 months. The 1- and 3-year OS rates in the LNS+ group were respectively 100 and 95.5% versus 99.4 and 91.6% in the LNS- group (P = 0.549). The 1- and 3-year DFS rates in the LNS+ group were respectively 100 and 94.2% versus 94.7 and 87.1% in the LNS- group (P = 0.117). The multivariate analysis showed that the presence of LNS did not affect OS (P = 0.918) or DFS (P = 0.209). CONCLUSIONS: The prognosis is excellent for patients with ypN0 rectal cancer who have LNS after preoperative chemoradiotherapy. The presence of LNS in ypN0 rectal cancer patients after chemoradiotherapy should not be considered a factor for a poor prognosis.

Sigmoid resection with primary anastomosis and ileostomy versus laparoscopic lavage in purulent peritonitis from perforated diverticulitis: outcome analysis in a prospective cohort of 40 consecutive patients.

PURPOSE: This prospective study aimed to compare outcomes after laparoscopic peritoneal lavage (LPL) and sigmoid resection with primary colorectal anastomosis (RPA). METHODS: From June 2010 to June 2015, 40 patients presenting with Hinchey III peritonitis from perforated diverticulitis underwent LPL or RPA. Patients with Hinchey II or IV peritonitis and patients who underwent an upfront Hartmann procedure were excluded. Primary endpoint was overall 30-day or in-hospital postoperative morbidity after surgical treatment of peritonitis. RESULTS: Twenty-five patients underwent RPA and 15 LPL. Overall postoperative morbidity and mortality rates were not significantly different after RPA and LPL (40 vs 67 %, p = 0.19; 4 vs 6.7 %, p = 1, respectively). Intra-abdominal morbidity and reoperation rates were significantly higher after LPL compared to RPA (53 vs 12 %, p < 0.01; 40 vs 4 %, p = 0.02, respectively). Multivariate analysis showed that LPL (p = 0.028, HR = 18.936, CI 95 % = 1.369-261.886) was associated with an increased risk of postoperative intra-abdominal septic morbidity. Among 6 patients who underwent reoperation after LPL, 4 had a Hartmann procedure. All surviving patients who had a procedure requiring stoma creation underwent stoma reversal after a median delay of 92 days after LPL and 72 days after RPA (p = 0.07). CONCLUSION: LPL for perforated diverticulitis is associated with a high risk of inadequate intra-abdominal sepsis control requiring a Hartmann procedure in up to 25 % of patients. RPA appears to be safer and more effective. It may represent the best option in this context.

Nutritional Status of Vegetarian Patients Before and After Bariatric Surgery: a Monocentric Retrospective Observational Case-Control Study.

The obesity pandemic is associated with an increasing number of bariatric surgeries which allow improvement in obesity-related comorbidities and life expectancy but potentially induce nutritional deficiencies. Vegetarianism becomes more and more popular and exposes as well to vitamin and micronutrient deficiencies. Only one study has explored the impact of vegetarianism on the preoperative nutritional status of eligible patients for bariatric surgery, but none in postoperative care. MATERIALS AND METHODS: We conducted a retrospective case-control study in our cohort of bariatric patients, matching 5 omnivores for each vegetarian. We compared their biological profile regarding vitamin and micronutrient blood levels before and 3, 6, 12, and 30 months after surgery. RESULTS: We included 7 vegetarians including 4 lacto-ovo-vegetarians (57%), 2 lacto-vegetarians (29%), and one lacto-ovo-pesco-vegetarian (14%). Three years after surgery with equivalent daily standard vitamin supplementation, the two groups showed a similar biological profile including blood levels of ferritin (p = 0.6), vitamin B1 (p = 0.1), and B12 (p = 0.7), while the total median weight loss at 3 years was comparable (39.1% [27.0-46.6] in vegetarians vs 35.7% [10.5-46.5] in omnivores, p = 0.8). We observed no significant difference between vegetarians and omnivores before surgery regarding comorbidities and nutritional status. CONCLUSION: It seems that, after bariatric surgery, vegetarian patients taking a standard vitamin supplementation do not show an increased risk of nutritional deficiencies compared to omnivores. However, a larger study with a longer follow-up is needed to confirm these data, including an evaluation of different types of vegetarianism such as veganism.

Five-Year Changes in Weight and Diabetes Status After Bariatric Surgery for Craniopharyngioma-Related Hypothalamic Obesity: a Case-Control Study.

PURPOSE: Craniopharyngiomas are tumors located in the hypothalamic region which leads to obesity in about 50% of cases. Long-term efficacy and safety of bariatric surgery are lacking in this peculiar population. The aim of this study is to determine the 5-year weight loss and resolution of type 2 diabetes (T2D) after bariatric surgery in patients operated on craniopharyngioma who had developed hypothalamic obesity. MATERIALS AND METHODS: This is a multicenter french retrospective case-control study. Subjects with craniopharyngioma (n = 23) who underwent sleeve gastrectomy (SG) (n = 9) or Roux-en-Y gastric bypass (RYGB) (n = 14) (median age 35 years [25;43] and BMI 44.2 kg/m2 [40.7; 51.0]; 8/23 with T2D) were individually matched to 2 subjects with common obesity for age, gender, preoperative body mass index, T2D, and type of surgery. RESULTS: TWL% after 1 and 5 years was lower in the craniopharyngioma group than in the control group: 23.1 [15.4; 31.1] (23/23) vs 31.4 [23.9; 35.3] at 1 year (p = 0.008) (46/46) and 17.8 [7.1; 21.9] (23/23) vs 26.2 [18.9; 33.9] at 5 years (p = 0.003) (46/46). After RYGB, TWL% was lower in the craniopharyngioma group compared to the control group (p < 0.001) and comparable after SG both at 1 and 5 years. No difference between the two groups was observed in T2D remission rate and in early and late adverse events. No hormonal deficiency-related acute disease was reported. CONCLUSIONS: Bariatric surgery induced a significant weight loss in the craniopharyngioma group at 1 and 5 years, but less than in common obesity. SG may be more effective than RYGB but this remains to be demonstrated in a larger cohort.

Complications Requiring Intensive Nutritional Care After Bariatric Surgery Result in More Long-Term Weight Loss but Has No Impact on Nutritional Deficiencies and Depression-Anxiety Scores.

PURPOSE: Bariatric surgery is associated with significant weight loss and improvement in comorbid conditions but in rare cases can expose to complications requiring intensive nutritional care (INC). INC in this context is poorly described and no data are available concerning long-term impact. MATERIALS AND METHODS: We retrospectively reviewed charts of bariatric patients who were hospitalized in our institution between 2013 and 2018. We identified patients with a postoperative complication requiring INC and we described their nutritional management (INC group). These patients were compared with controls matched to age, gender, preoperative BMI, and type of surgery selected from our database (control group). The primary endpoint was the percentage of total weight loss (%TWL) at 2.5 years. Secondary endpoints were improvement of co-morbidities, vitamin deficiencies, and depression/anxiety scores. RESULTS: The INC group consisted of 18 patients among which 77.8% had sleeve gastrectomy (SG). Half of these patients underwent revisional surgery. The most common complication was fistula formation (66.7%). Patients in the INC group, compared to the control group, showed a significantly higher %TWL at 2.5 years (33.6% vs 26.1%, P = 0.03). There was no significant difference in either reduction of preoperative comorbidities or depression/anxiety scores between the two groups. The number of patients with more than three nutritional deficiencies was similar in both groups. Thiamine deficiency was only observed in the INC group. CONCLUSION: Complications requiring INC after bariatric surgery occur mainly after revisional surgery and may increase long-term %TWL but have no impact on nutritional deficiencies or symptoms of anxiety/depression.

Management of acute malignant large-bowel obstruction with self-expanding metal stent.

PURPOSE: Colorectal stents are being used for palliation and as a "bridge to surgery" in obstructing colorectal carcinoma. The purpose of this study was to review our experience with self-expanding metal stents (SEMS) as the initial interventional approach in the management of acute malignant large-bowel obstruction. METHODS: Between February 2002 and August 2009, 93 patients underwent the insertion of a SEMS for an obstructing malignant lesion of the left-sided colon or rectum. RESULTS: In 66 patients, the stents were placed for palliation; whereas, in 27 patients they were placed as a bridge to surgery. Stent placement was technically successful in 92.5% (n = 86) of the patients, with a clinical success rate of 86% (n = 80). Three perforations occurred during stent placement, two were treated by an emergency Hartmann operation, and one by a colostomy. In the intention to treat by stent, the peri-interventional mortality was 6.5% (6/93). Stent migration was reported in three cases (3%), and stent obstruction occurred in 11 cases (12%). Of the 24 patients with stents successfully placed as a bridge to surgery, 22 underwent elective single-stage operations with no death or anastomotic complication. CONCLUSION: Stent insertion provided an effective outcome in patients with malignant colonic obstruction as a palliative and preoperative therapy.

Intraperitoneal mesh repair of small ventral abdominal wall hernias with a Ventralex hernia patch.

BACKGROUND: Various surgical procedures have been described in the treatment of small ventral abdominal wall hernias. Mesh repair is becoming popular because of a low recurrence rate. AIM: The aim of this prospective study was to evaluate an open intraperitoneal technique using the Bard Ventralex hernia patch in the treatment of small midline ventral hernias. METHODS: 101 patients were operated on (59 male, 42 female) with a mean age of 54.5 years (range 17-85). Mean operative time was 33 min (range 16-65). The median hospital stay was 2 days (range 1-15). RESULTS: Two patients had a hematoma without wound infection. There were 2 recurrences (2%). Mean postoperative follow-up time was 28.5 months (range 6-55). CONCLUSIONS: Our preliminary results suggest that Ventralex hernia patch repair for ventral hernias can be performed with minimal postoperative morbidity and a low recurrence rate.

Ventral hernia surgery in morbidly obese patients, immediate or after bariatric surgery preparation: Results of a case-matched study.

BACKGROUND: Obesity is a risk factor for the development of ventral hernia and increases the risk of recurrence and surgical site infection after hernia repair (HR). OBJECTIVES: We tested the hypothesis that bariatric surgery (BS) before HR would decrease these risks in patients with morbid obesity. SETTING: University hospital, France. METHODS: We retrospectively compared 2 groups of patients with morbid obesity in a case-matched study; 1 underwent immediate HR surgery (control), and the other initially underwent BS and then HR after weight loss (case). Patients were individually matched at a 2:1 ratio according to defect size (<7 or ≥7 cm), obesity grade (<40 or ≥40 kg/m²), American Society of Anesthesiologists score, sex, smoker status, and presence of chronic obstructive pulmonary disease. RESULTS: From 2000 to 2017, 41 patients underwent BS, in association with herniorrhaphy in 14 cases (34%). Initial body mass index was higher in the BS group (46.7 ± 6.4 versus 42.4 ± 7.2, P < .0001) but had decreased by the time of HR (34.1 ± 6.5 versus 42.3 ± 7.2, P < .0001). Prosthetic HR was performed after 21.5 months (range, 7-87); however, 7 patients did not receive HR at this time due to insufficient weight loss. Postoperative morbidity was similar in the 2 groups. Hospital stay was shorter in the BS group (6.2 ± 2.6 versus 10.7 ± 9.3 d, P = .002). After a median follow-up of 4.6 ± 4.1 years, the recurrence rate was lower in the BS group (2/30, 6.7%) than in the control group (12/50, 24%; P = .048). CONCLUSION: For morbidly obese patients with ventral hernia, BS before HR surgery can decrease recurrence without increasing morbidity.

Effect of Bariatric Surgery-Induced Weight Loss on Platelet Count and Mean Platelet Volume: a 12-Month Follow-Up Study.

BACKGROUND: Abdominal obesity is strongly correlated with cardiovascular risk and associated with platelet hyperactivity. This hyperactivity is associated with an increase in mean platelet volume (MPV). Few data are available about changes in platelet counts and MPV in obese patients after bariatric surgery (BS). The purpose of this study was to describe quantitative and qualitative changes in the platelet lineage after BS. METHODS: One hundred twenty-eight consecutive patients were included. The mean age was 43 ± 12 years, 77 % of patients were female, and the mean preoperative BMI was 44 ± 6 kg/m2. Ninety patients (71 %) had a Roux-en-Y gastric bypass (RYGBP), and 38 (29 %) had a sleeve gastrectomy (SG). Patients were evaluated preoperatively, and postoperative follow-up was performed at 3, 6, and 12 months. The postoperative evaluation included blood samples for full blood count (FBC), including measure of mean platelet volume (MPV). RESULTS: At the 12-month follow-up, the reduction in preoperative weight was 29 ± 9 %. We showed a significant decrease in platelet count (245 ± 62 vs. 234 ± 54 G/L; p = 0.0015) found in parallel with a non-significant decrease in MPV (9.27 ± 1.1 vs. 9.22 ± 1.05; p = 0.34). With regard to the intervention type, SG caused a more significant decrease in platelet count than RYGBP (p = 0.02). There was no significant difference in MPV variations between the two groups (p = 0.08). CONCLUSIONS: Our results suggest that BS has a positive impact on platelet metabolism, possibly mediated by weight loss. These data need to be confirmed to understand the multifactorial benefits of BS on cardiovascular risk in obese patients.

Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: an audit of 34 patients.

BACKGROUND: Weight loss failure and proton pomp inhibitor (PPI)-resistant gastroesophageal reflux diseases (GERD) after sleeve gastrectomy (SG) are frequently encountered. OBJECTIVES: The aim of this study was to evaluate the efficacy and risks of SG conversion to Roux-en-Y gastric bypass (RYGB) in the case of weight loss failure or severe GERD. SETTING: University hospitals. METHODS: Between March 2007 and December 2014, 34 patients with history of SG underwent RYGP. A retrospective analysis of a prospectively collected database was undertaken. RESULTS: Among 34 patients, 31 underwent revisional surgery for weight loss failure and 3 for PPI-resistant GERD. Six patients in the weight loss failure group had symptomatic GERD that was effectively treated with PPIs. The average body mass index (BMI) was 53±11 kg/m2 before SG. A laparoscopic approach was performed in 94% of patients. There was no postoperative mortality. Major adverse events (<90 days) occurred in 4 patients (11.7%). The mean length of stay was 6.7±2.8 days. At the time of revisional surgery, the mean BMI, percentage excess weight loss, and percentage weight loss were 44.7±9.8 kg/m2, 33.6±27.1%, and 16±9.7%, respectively, compared with 40.9±8.5 kg/m2, 63.1±36.2%, and 23.8±14% at 3 years. The GERD was resolved in all patients, allowing the cessation of PPI medication. CONCLUSION: Laparoscopic conversion of SG to RYGB is feasible and it allows improvement in secondary weight loss and GERD, but at the cost of high morbidity.