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.

Assessment of the optimal timing for early laparoscopic cholecystectomy in acute cholecystitis: a prospective study of the Club Coelio.

Background: The optimal timing for cholecystectomy in patients with acute cholecystitis remains controversial. The aim of this study is to assess prospectively the impact of the duration of symptoms on outcomes in early laparoscopic cholecystectomy (ELC) for acute cholecystitis. Methods: The series consisted of 276 consecutive patients who underwent ELC for acute cholecystitis in 2016. The patients were divided into three groups according to the timing of surgery: within the first 3 days (group 1), between 4 and 7 days (group 2) and beyond 7 days (group 3) from the onset of symptoms. Results: The percentage of surgical procedure rated as difficult was respectively: 12% in G1, 18% in G2 and 38% in G3 (p < .001). Accordingly, we observed an increased mean operative time within groups but no significant difference in the conversion rate. We noted a different overall postoperative complication rate within groups, respectively: 9% in G1, 14% in G2 and 24% in G3 (p < .04). The median hospital stay was also different within groups, respectively: 3 in G1, 4 in G2 and 6 days in G3 (p < .001). On univariate analysis, age ≥60, male gender, ASA 3, WBC ≥13.000/µL, CRP ≥100 mg/l and delay between onset of symptoms and surgery were factors statistically associated with increased morbidity rate. On multivariate analysis, the delay was the only independent predictive factor of postoperative morbidity (OR: 1,08, 95% CI: 1.01-1.61, p < .031). Conclusion: Our study confirms that it is ideal to perform ELC within 3 days of symptoms onset and reasonable between 4 to 7 days. We do not recommend performing ELC beyond 7 days because of more difficult procedure and significantly increased risk of post-operative complications.

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.

Is early enteral nutrition dangerous in acute non surgical complicated diverticulitis? About 25 patients fed with oral fiber free energetic liquid diet.

BACKGROUND AND STUDY AIMS: Complicated Acute Colonic Diverticulitis (ACD) is usually treated by parenteral way thus keeping the bowel at rest. To date there are no clear recommendations regarding the route of nutrition administration. We study the safety of early feeding by oral energetic fiber-free liquid diet in non-surgical complicated ACD patients. PATIENTS AND METHODS: From February 2008 to October 2011, 25 patients were admitted with complicated ACD and took part in this prospective study. Surgical and medical assessments were performed at admission. Initial treatment was given with perfusion, intravenous antibiotics and hydric diet. Within 72 hours of admission, antibiotic therapy was switched to oral administration for 5 up to 15 days depending on the progression of the disease. At the same time the patient received oral liquid fiber-free feeding. Solid but fiber-free diet was introduced 24h hours before discharge. RESULTS: 25 cases of ACD were complicated with covered perforation and/or abscess. Mean hospitalisation time was 10A.4 days. 23 cases had good recovery and discharged, while 1 case progressed to colonic stenosis during hospitalisation, requiring a sigmoidectomy with a one-time anastomosis with good recovery. One patient relapsed his abscess during hospitalisation despite CT guided drainage and required sigmoidectomy with transient ileostomy. The mean daily treatment and nutrition cost for the non-surgical 23 patients was 30 euros. CONCLUSIONS: Early enteral nutrition in complicated ACD is feasible, not harmful, and reduce both, mean hospitalization time and treatment cost. Further studies comparing enteral with parenteral nutrition are necessary to confirm our hypothesis.

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.

Single umbilical incision laparoscopic cholecystectomy: results of the prospective trial of the Coelio Club.

AIM: To assess the cosmetic outcome after single umbilical incision laparoscopic cholecystectomies (SILC) performed by the surgeons of the Coelio Club. PATIENTS AND METHODS: Multicenter prospective study concerning 105 consecutive patients operated between December 2009 and February 2011 by SILC for non-complicated gallstones. Perioperative and postoperative parameters were analyzed with a systematic follow-up at 1 and 6months postoperative. RESULTS: Conversion to conventional laparoscopic cholecystectomy (CLC) was required for six patients (5.7%). Conversion rate is higher in case of acute cholecystitis (25%, P<0.001). Cosmetic outcome is found excellent by the patient (in 86% of the cases at 6months) and by the surgeon (in 90% of the cases at 6months) using an EVA scale. An incisional hernia was found in two cases (1.9%) and a superficial wound infection in four cases (3.8%). CONCLUSIONS: The cosmetic outcome after SILC is found excellent. SILC has its place in the surgical management of the non-complicated gallstone. We did not notice higher level of peroperative complications (biliary tract injury) during SILC than during CLC. Postoperative higher level of abdominal wall complications than after a CLC makes the surgeon caution to a careful abdominal wall closure.

[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.

Prevention of parastomal hernia by intraperitoneal onlay mesh reinforcement at the time of stoma formation.

PURPOSE: Parastomal hernia (PSH) is a very frequent complication after creation of a permanent colostomy. The aim of this study is to assess the safety and prophylactic effect of intraperitoneal onlay mesh (IPOM) reinforcement of the abdominal wall at the time of primary stoma formation to prevent PSH occurrence. MATERIALS AND METHODS: This multicentre prospective study concerned 20 patients operated for low rectal carcinoma between 2008 and 2010. Those patients had an elective and potentially curative abdominoperineal excision associated with IPOM reinforcement of the abdominal wall with a round composite mesh centred on the stoma site and covering the lateralised colon. There were 8 men and 12 women with a median age of 69 years (range: 44-88) and a body mass index of 27 (range: 21-35). The major outcomes analysed in the study were operative time, complications related to mesh and PSH occurrence. Patients were evaluated 1 month after surgery and then every 6 months with physical examination and computed tomography scan (CT-scan). For PSH, we used the classification of Moreno-Matias. RESULTS: Surgery was performed by laparoscopy in 17 patients and by laparotomy in 3; 12 had an extraperitoneal colostomy, and 8 had a transperitoneal colostomy. The median size of the mesh was 15 cm (range: 12-15). The median operative time was 225 min (range: 175-300), and specific time for mesh placement was 15 min (range: 12-30). One month after surgery, one patient presented with a mild stoma stenosis that was treated successfully by dilatation. With a median follow-up of 24 months (range: 6-42), no other complication potentially related to the use of the mesh was recorded and no mesh had to be removed. On clinical examination, one patient (1/20 = 5 %) had a stoma bulge that appeared a few months after surgery, but was not associated with symptoms. CT-scan evaluation confirmed that all the patients with a normal clinical examination had no PSH and revealed that the patient with the stoma bulge had a stoma loop hernia (type 1a hernia). This patient was followed up for 36 months, no clinical or radiological aggravation of the stoma loop hernia was observed, and he remained totally asymptomatic. CONCLUSIONS: With 95 % of excellent results, IPOM reinforcement at the time of end colostomy formation in selected patients is a very promising procedure. A drawback of this technique is the possibility of developing a stoma loop hernia due to sliding of the exiting colon between the covering mesh and the abdominal wall. However, this risk is low, and no adverse clinical consequence for the patient was noted in our series.

Single umbilical incision laparoscopic cholecystectomy: initial experience of the Coelio Club.

AIM: To assess the initial results of single umbilical incision laparoscopic cholecystectomies (SUILC) performed by the members of the Club Coelio. PATIENTS AND METHODS: This multicenter study involved 65 consecutive patients undergoing SUILC between September 2008 and December 2009. The operation was performed with a 0° scope in 35 and with a 30° scope in 30 patients. There were 56 women and nine men with a mean age of 49 ± 14 years and a mean body mass index of 25 ± 4. The main perioperative parameters analyzed were duration of operation, conversion, morbidity and duration of hospitalization. One month after surgery, the esthetic result was assessed by each patient on a visual analogue scale (VAS). A VAS score between 9 and 10 was considered as an excellent result. RESULTS: During laparoscopy, some degree of cholecystitis was seen in 10 patients. Intraoperative cholangiography was performed in 57 patients and the mean duration of operation was 68 ± 22 min. Conversion to conventional laparoscopic cholecystectomy (CLC) was required in eight patients (12%). We noted three complications (4%): two wound abscesses and one hemoperitoneum. The mean hospital stay was 2 ± 1 days. The esthetic result was considered as excellent by 45 patients (69%). Multivariable analysis revealed that duration of operation was shorter after five procedures (61 ± 25 vs. 72 ± 18 min, regression coefficient: -7, P<0.032) and when a 30° scope was used (56 ± 18 vs. 76 ± 20 min, regression coefficient: -14, P<0.011), the conversion rate was higher in cholecystitis (60% [6/10] vs. 4% [2/55], OR: 33, P<0.002) and the percentage of excellent esthetic results was greater in patients who did not required a conversion to CLC (77% [44/57] vs. 12% [1/8], OR: 18, P<0.012). CONCLUSIONS: Our study showed that SUILC is feasible with low morbidity but duration of operation is long and conversion to CLC is frequent in cholecystitis. However, duration of operation decreases with rising experience of the surgeon and when a 30° scope is used. The major value of this technique is cosmetic.

Classification of primary and incisional abdominal wall hernias.

PURPOSE: A classification for primary and incisional abdominal wall hernias is needed to allow comparison of publications and future studies on these hernias. It is important to know whether the populations described in different studies are comparable. METHODS: Several members of the EHS board and some invitees gathered for 2 days to discuss the development of an EHS classification for primary and incisional abdominal wall hernias. RESULTS: To distinguish primary and incisional abdominal wall hernias, a separate classification based on localisation and size as the major risk factors was proposed. Further data are needed to define the optimal size variable for classification of incisional hernias in order to distinguish subgroups with differences in outcome. CONCLUSIONS: A classification for primary abdominal wall hernias and a division into subgroups for incisional abdominal wall hernias, concerning the localisation of the hernia, was formulated.

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.

Laparoscopic cure of small ventral hernias with composite mesh.

BACKGROUND: The use of mesh is recommended to reduce the rate of recurrence after the curing of ventral hernias. METHODS: A multicentre prospective trial was conducted to assess the laparoscopic cure of small ventral hernias with a composite mesh. RESULTS: Around 222 patients entered the trial and received laparoscopic repair for ventral hernias of less than 5 cm. There was one conversion. The mean length of post-operative hospitalisation was 2.5 days. At 1 year, the recurrence rate was 2%. Two meshes were removed due to infection, 3% of the patients were using analgesics and 86.1% of the patients described no pain on EVA scoring. CONCLUSION: The laparoscopic cure of small ventral hernias with composite mesh is efficient. Further technical progress is warranted to reduce the rate of seroma formation.

[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.

Laparoscopic treatment of pancreatic pseudocysts.

BACKGROUND: A multicentric study was performed to evaluate the clinical results after laparoscopic treatment of pancreatic pseudocysts (PP). METHODS: We collected the data of 17 patients presenting with PP and operated on by laparoscopy between 1996 and 2001. There were nine men and eight women with a median age of 42 years (range 30-72). In 15 patients the PP developed after acute pancreatitis and the median delay between the acute onset and surgery was 7 months (range: 2-24). In two patients the PP was associated with chronic pancreatitis. All the patients had a single PP with a median diameter of 9 cm (range: 5-20). RESULTS: According to the location of the PP, a cystogastrostomy was performed in 10 patients and a cystojejunostomy in seven patients. The median operative time was 100 min (range: 80-300). Laparoscopic PP surgery was completed successfully in 16 patients and the median size of the cystoenterostomy was 3 cm (range: 2-5). Necrotic debris was present within the PP in 11 patients. The median postoperative hospital stay was 6 days (range: 4-24). No mortality and no immediate morbidity were recorded. However, two patients were readmitted within the first 3 postoperative weeks because of secondary PP infection. The first patient had an early closure of cystogastrostomy and was treated by endoscopic placement of a stent. The second represented with a right retrocolic abscess after cystojejunostomy and was treated by percutaneous drainage. One patient was lost for follow-up 2 months after surgery. The others had regular clinical and radiological controls. With a median follow-up of 12 months (range: 6-36), no recurrence of PP was observed. CONCLUSIONS: The laparoscopic treatment of PP was associated with a low postoperative complication rate and an effective permanent result. That approach avoided some difficulties, particularly bleeding that is classically linked with endoscopic internal drainage.

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.

Quality of life assessment after Nissen fundoplication.

The aim of this study was to evaluate the quality of life of 31 patients presenting with gastroesophageal reflux (GORD) and operated on by Nissen fundoplication. The series consisted of 23 men and 8 women; the median age was 39 years (range 22-65) and the median follow-up 36 months (range 18-74). We used a new questionnaire: the Gastrointestinal Quality of Life Index (GIQLI) that includes 36 items and uses a five-graded Likert scale (from 0 to 4) giving a maximum score of 144. This score includes five dimensions: symptoms, emotions, vitality, social relations and medical treatment. The pre- and postoperative GIQLI scores observed in the Nissen group and the score of a control group of 110 healthy patients were compared with each other. The preoperative score (71 +/- 21) was greatly impaired compared to the score (123 +/- 13) of the control group (p < 0.0001). The postoperative score (109 +/- 21) increased significantly (p < 0.0001) but remained statistically inferior to the score of the control group (p < 0.005). The analysis of the dimensions showed that the postoperative score of the symptoms was lower in the Nissen group: 56 +/- 9 versus 66 +/- 6 in the control group (p < 0.0005) whereas no statistical difference was found for the four other dimensions. This lower symptoms score was not due to recurrence of GORD symptoms but to the occurrence of flatulence and to the persistence of gurgling noises and gas bloating. In conclusion, the quality of life of the patients requiring surgery for gastroesophageal reflux was greatly impaired, it largely improved after Nissen fundoplication but did not reach the level of healthy patients because of unrelated GORD gastrointestinal symptoms.

[Assessment of quality of life after antireflux surgery]. / Evaluation de la qualité de vie après chirurgie antireflux.

AIM OF THE STUDY: To assess the quality of life (QoL) of patients operated for gastroesophageal reflux disease (GERD). PATIENTS AND METHODS: This prospective study included 82 consecutive patients submitted to antireflux surgery between October 1998 and January 1999. A new questionnaire was used to assess their QoL: the Gastrointestinal Quality of Life Index (GIQLI) that includes 36 items concerning 5 dimensions: symptoms, vitality, emotions, social relations and medical treatment. The series consisted of 44 men and 38 women with a mean age of 47 years (range: 18-78). QoL was assessed before and 6 months after surgery; the follow-up rate was 94% (77/82). The pre- and postoperative GIQLI scores of the study group and the GIQLY score of a control group of 110 healthy patients were compared. RESULTS: Before surgery, the GIQLI score (90 +/- 23) was greatly impaired compared to the score (123 +/- 13) observed in the control group (p < 0.001). After surgery, the GIQLI score (110 +/- 23) increased significantly (p < 0.001), but remained statistically lower than the score of the control group (p < 0.001). The postoperative score recorded in the symptoms dimension was lower than the control group score: 55 +/- 11 versus 66 +/- 6 (p < 0.001), while no significant difference was observed in the other 4 dimensions. Univariate statistical analysis revealed that the postoperative GIQLI score (y) was correlated with the preoperative GIQLI score (x) according to the formula: y = 0.43 x + 71 (p < 0.001) and the sex of the patients, as the postoperative GIQLI score was higher in male patients (115 +/- 19) than in female patients (103 +/- 23) (p < 0.02). CONCLUSION: The QoL of the patients was greatly improved after antireflux surgery, but remained lower than that of a control group of healthy subjects. Better patient selection should improve the results. In our series, male patients or patients with a high preoperative GIQLI score were the best candidates for antireflux surgery.