Weight loss and quality of life after bariatric surgery: a study of 200 patients after vertical gastroplasty or adjustable gastric banding.

BACKGROUND AND OBJECTIVES: Long term evaluation of bariatric surgery must include quality of life measurement. METHODS: Quality of life (QoL) was evaluated using the original Moorehead-Ardelt questionnaire for 200 patients operated for massive obesity in a single centre between 1994 and 2003. QoL and physical data were obtained by retrospective mail questionnaire. Surgical procedures were vertical-banded gastroplasty according to Mason (VBGM) and adjustable gastric banding (AGB) in 61 and 39% of patients, respectively. The aim of the study was to assess the nutritional outcome and QoL according to the procedure. RESULTS: Overall, the body mass index (BMI) decreased from 50+/-8 kg/m(2) before surgery to 35.2+/-7.5 kg/m(2) at the time of the questionnaire. The percentage of weight loss was 28.8+/-12.2%. In the group treated with VBGM, the mean initial weight (P=0.003) and the percentage of weight loss (P<0.001) were significantly higher, and the QoL was better (P=0.003) than in the group treated with AGB. On the basis of the time spent since surgery, a regular weight loss was observed during the first 5 years, whereas weight subsequently increased over the five following years. Similarly, the total QoL score gradually improved during the first 5 years and worsened thereafter. However, it remained better than before surgery. A linear regression analysis showed a positive correlation between the percentage of weight loss and the QoL score (P<0.001). CONCLUSIONS: This study suggests that the bariatric surgery, particularly the VBGM technique, improved the QoL of obese patients, at least in the first 5 years following surgery.

[Laparoscopic ovarian transposition and cryopreservation of ovarian tissue before chemo-radiotherapy for rectal cancer]. / Transposition ovarienne par coelioscopie et cryopréservation de tissu ovarien avant radiochimiothérapie d'un cancer du rectum.

We report a case of laparoscopic ovarian transposition and ovarian cryopreservation in a nulliparous 25-year-old woman with rectal cancer. The authors focus on the surgical technique and the importance of preserving ovarian function.

[Management of pregnancies after adjustable gastric banding]. / Prise en charge des grossesses après anneau gastrique ajustable.

OBJECTIVES: To report our experience of the association adjustable gastric banding and pregnancy. To define a management for a such association. MATERIALS AND METHODS: Retrospective and descriptive study on two centers over a 3-year follow-up of pregnancies begun with a Lap-Band gastric banding placed by laparoscopic way. RESULTS: Twenty-one pregnancies, 22 newborns resulting from 18 women were identified. Eleven patients were hospitalized. The motive of the hospitalization was severe epigastralgia for four patients requiring three deflations for mechanical complication. No case of preeclampsia was identified. Seven bands were deflated. In the group of the deflated bands, the mean maternal weight gain was 19 vs 10 kg (P=0.008), the mean birth weight was 3700 vs 3204 g (P=0.09) with a rate of fetal macrosomia increased, 50 vs 29% (P=0.038). The difference between the rates of cesarean delivery was not significant (NS) between the two groups. The childbirth term was appreciably the same, 39.4 vs 38.6 weeks of gestation (NS). The only case of gestational diabetes was found in the deflated band group. Three intrauterine growth restrictions whose one fetal death occurred in the not deflated band group. CONCLUSION: Results obtained were comparable to those of the literature. This series confirms that adjustable gastric banding limits the usual complications of the morbid obesity during pregnancy. It is generally well tolerated and must not be thus deflated by principle, but only on symptoms. That will be a total dysphagia, severe epigastric pains, vomiting after the first trimester of pregnancy or an intrauterine growth restriction.

Absence of expression of interleukin-6 (IL-6) mRNA in regenerating rat liver.

The serum level of IL-6 and expression of IL-6 mRNA in hepatocytes from regenerating liver were investigated in the rat. The IL-6 level in the serum was not significantly different from that of a control group of rats submitted to an acute experimental inflammation. IL-6 mRNA expression did not occur in the liver of hepatectomized rats as judged from Northern blotting experiments using an IL-6 riboprobe. These results suggest that if IL-6 is implicated in hepatic regeneration, this cytokine is not produced by the regenerating liver and must be delivered exogenously to the liver to modulate hepatic regeneration.

Assessment of prolonged hospital stay attributable to surgical site infections using appropriateness evaluation protocol.

BACKGROUND: The accepted standard in estimating the stay prolongation attributable to surgical site infections is the matched-cohort study method (MCS), which is associated with selection bias. The Appropriateness Evaluation Protocol (AEP) has been used to estimate stay prolongation attributable to nosocomial infections but has not been validated specifically for surgical site infections. AIM OF THE STUDY: To compare estimates of stay prolongation attributable to surgical site infections after digestive surgery, obtained by AEP and by MCS. METHODS: Sixty-five surgical site infections after digestive tract surgery were analyzed by AEP and MCS. AEP stay prolongation was the number of days judged specifically appropriate for the care of surgical site infections. MCS stay prolongation was the difference of stay duration in surgical site infection cases and two controls matched by age, sex, and diagnosis-related groups. Sensitivity and specificity of AEP, and agreement between both methods, were calculated. RESULTS: The mean AEP stay prolongation was 3.5 days vs 7.2 days for MCS. The sensitivity of AEP was 58% and the specificity was 75%. The agreement between the two methods was poor. CONCLUSION: Surgical site infections after digestive tract surgery increased the hospital stay. Accurate estimations of a prolongation of stay will vary according to the method selected.

Motility in the Roux-Y limb after distal gastrectomy: relation to the length of the limb and the afferent duodenojejunal segment--an experimental study.

Following gastrectomy, the longer is a Roux-Y limb constructed to restore digestive continuity the higher the frequency of postoperative symptoms. The aim of this experimental study was to test how the level of the jejunal transection and the length of the Roux limb affect the motility of the constructed limb and in particular the onset and the propagation of activity fronts (AFs). Three months after a distal Roux-en-Y gastrectomy, electromyographic tracings were recorded in six groups of rats grouped according to the level of the transection (20 or 40 cm from the pylorus) and the length of the limb (10, 20 or 30 cm). Animals in which a simple laparotomy or laparotomy + jejunal transection was performed, served as controls. During the interdigestive period, all animals had AFs in the limb which were independent from those recorded in the duodenum. In the limb, the mean time interval between two AFs was shorter (P < 0.01) and more irregular than in controls. An increase in limb length was associated with a lower incidence of completely propagated AFs (P < 0.05) and a higher incidence of irregularly propagated AFs (P < 0.01). When propagation of the AFs was analysed both in the limb and in the jejunum distal to the anastomosis, propagation abnormalities were more frequent. Below the gastrojejunal anastomosis, for an intestinal length of either 20 or 30 cm, the frequency of abnormal AFs was not different when this length was either only a limb or a limb with the 10 cm of distal jejunum below the jejuno-jejunal anastomosis. Interruption of AFs by a meal was irregular in the limb and more rarely observed in the 30-cm than in 10-cm limbs (P < 0.05). Interruption of AFs was shorter than in controls (P < 0.01). In the duodenum and the jejunum proximal to the limb, the interval between AFs was higher than in controls and in the Roux-Y limbs (P < 0.001). Intraluminal concentrations of bacterial strains were not different in the different types of limb while lactobacillus concentrations and pooled concentrations of bacteria were higher than in controls (P < 0.05). No relationship was found between the incidence of myoelectric abnormalities and intraluminal bacterial concentrations. Increasing the length of a Roux-Y limb resulted in more frequent disturbances in AFs in the limb but had no significant consequence on the overall rate of abnormal AFs in the jejunum distal to the transection. Motor response to food intake was also reduced. Motor changes were not related to intraluminal bacterial concentrations.

Upper jejunal motility after pancreatoduodenectomy according to the type of anastomosis, pancreaticojejunal or pancreaticogastric.

BACKGROUND: The goal of this study was to compare upper jejunal motor patterns after Billroth II pancreatoduodenectomy according to the type of pancreatic anastomosis (pancreaticojejunostomy [PJA] or pancreaticogastrostomy [PGA]) and the presence or absence of postoperative symptoms. STUDY DESIGN: Manometric recordings during fasting and after a 750-kcal meal were performed in the afferent limb in 12 patients (7 PJA, 5 PGA) and in the efferent limb in 15 other patients (7 PJA, 8 PGA) with a postoperative delay of 15+/-6 days and 3.9+/-2.2 months respectively. Patient data were compared to those of 20 healthy controls. RESULTS: During fasting, the 2 main abnormal findings were a higher incidence (p < 0.05) and a slower migration velocity (p < 0.01) of incomplete phase III by comparison with that recorded in controls. No difference for phase III was observed between the 2 surgical procedures regardless of recording site. Trimebutine, 100 mg intravenously, induced a phase III in 89% (24 of 27) of the patients. Delay of motor response varied from 5 to 10 minutes without difference between the recording site; it was less than 2 minutes in 100% of controls. Trimebutine-induced phase III showed similar propagation abnormalities to the spontaneous phase III. Duration of the fed pattern (p < 0.001) and motor index (p < 0.001) were significantly lower than in controls after the meal, in both limbs, whatever the type of anastomosis. Differences between the 2 surgical procedures were a slower migration velocity of phase III (p < 0.01) and a lower postmeal motor index (p < 0.05) in the efferent limb after PJA than after PGA. Nine of 27 patients were symptomatic. In these 9 patients, mean phase III migration velocity was slower (p < 0.001), and mean area under the postprandial curve was higher (p < 0.01) than in asymptomatic patients. Propagated clusters of contractions were only found in symptomatic patients and in the afferent limb. CONCLUSIONS: Pancreatoduodenectomy is associated with significant motor disturbances, mainly slower phase III and a reduced fed pattern, in the upper jejunum, at least during the first 3 postoperative months. Few motor differences were observed between PGA and PJA pancreatic anastomosis. A lesser occurrence of postsurgical motor anomalies does not appear to be an argument for preferring PGA to PJA.

Interleukin-6 (IL-6) and acute-phase proteins in rats with biliary sepsis.

We measured serum interleukin-6 (IL-6) and acute-phase proteins, alpha 1-acid glycoprotein (AGP) and alpha 2-macroglobulin (alpha 2M), after a retrograde intrabiliary bacterial infection in rats with biliary obstruction. Maximum serum IL-6 was obtained at 6 h in rats following inoculation of bacteria (10(6) CFU/ml E. Coli) in the bile duct and it was higher than that observed in rats undergoing a bile duct ligation or a laparotomy. There was a strict relationship between the level of IL-6 at 6 h and the modified levels of AGP and alpha 2M at 48 h. AGP and alpha 2M levels were the highest in sera of rats with bile duct infection as compared with those found in sera of rats with bile duct ligation or laparotomy. After inoculation of E. Coli or E. Fecalis, blood IL-6 level was always higher at 6 h in inferior vena cava as compared with that found in the supra hepatic vein. These results indicate that IL-6 is synthesized after a biliary sepsis and that its blood level is higher in the systemic circulation than in the local circulation.

When can revascularization be limited to the profunda femoris alone?

Dealing with lower limbs arteriopathies with combined aorto iliac and superficial femoral occlusive diease and when ischemia leads to operation should an extension bypass to the popliteal or tibial artery be associated every time it is possible? The authors have investigated the results of revascularizing operation above the profunda femoris on 35 limbs (27 patients). On 19 limbs only, has the revascularization been sufficient to cure the distal ischemia. On the other 16 limbs, a second operation was necessary 7 times an extension bypass to the popliteal or tibial artery, once an above knee amputation, twic a below knee amputation. From the comparison of these results with the degree of ischemia and the arteriographic aspect of the profunda femoris, the author's conclusion is that revascularization must extent below the profunda femoris unless the profunda is in good condition and there is no rest ischemia.

Squamous cell carcinoma of the thoracic esophagus following radiation therapy for breast cancer.

Between 1981 and 1995, 4 patients (3 females, 1 male; aged 48-80) were diagnosed with squamous cell carcinoma of the esophagus, following mediastinal irradiation for breast cancer. The interval between irradiation and the presentation of esophageal cancer was 10.75 years on average (7-19). The treatment consisted of: radiotherapy only; a partial esophagectomy with proximal gastrectomy without post-operative radiotherapy; laser photocoagulation for a superficial tumor; and, palliative treatment including gastrostomy, tracheal photocoagulation and chemotherapy for 1 patient suffering from advanced stage cancer with tracheal invasion, respectively. Radiotherapy of the esophageal cancer (exclusive or adjuvant) should take into account previous esophageal radiation therapy. The indications of curative excision surgery are the same as for other types of esophageal cancer, but the anastomoses should be performed in a non-irradiated area. Excision by esophageal stripping without thoracotomy is contraindicated because of the presence of peri-esophageal sclerosis. Preventive measures in radiation therapy for breast cancer are suggested.

Ileoanal anastomosis for ulcerative colitis: results of an evolutionary surgical procedure.

BACKGROUND/AIMS: Proctocolectomy with ileoanal anastomosis (IAA) has proved to be the most suitable surgical treatment for ulcerative colitis. The aim of this study was to compare the results of IAA according to the evolution of surgical procedures and particularly to compare the results of stapled versus hand-sewn anastomosis. METHODOLOGY: From 1984 to 1996, 37 men and 31 women were operated on in our centre for ulcerative colitis. The anastomosis between the J pouch and the dentate line was handsewn in 35 patients (group 1) and stapled in 33 patients (group 2). RESULTS: The mean operative time was significantly shorter in group 2 as compared with group 1 (265+/-59 vs. 323+/-53, p<0.01, respectively), whereas morbidity and functional results were comparable in both groups. In 10 patients with stapled IAA, a diverting ileostomy was not performed and the morbidity in this group did not increase. CONCLUSIONS: These results suggest that stapled IAA anastomosis is a safe procedure. The stapling technique of IAA simplifies total excision of the rectum and could mean that a diverting ileostomy is not necessary.

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.

[Study with flow cytometry of the peritumoral mucosa adjacent to colorectal cancers]. / Etude en cytométrie en flux de la muqueuse péritumorale adjacente aux cancers colorectaux.

Tumour and peritumoral mucosa were analyzed using flow cytometry in 21 consecutive patients operated on for colorectal carcinoma. Thirteen tumours were DNA aneuploid. No foci of aneuploidy bordering the tumours were detected, regardless of the tumour type. On the other hand, a significant decrease in the proliferative index was observed adjacent to the DNA aneuploid tumours. This study provides an additional argument for segmentary excision in colorectal cancers. Complementary studies are still required to specify the mechanisms of proliferation inhibition in the area of the DNA aneuploid tumours.

[Constipation symptoms studied by a standard questionnaire and anorectal manometry before and after promontory rectopexy (Orr-Loygue technic) in 25 female patients]. / Symptômes de constipation étudiés par un questionnaire standardisé et manométrie anorectale avant et après rectopexie au promontoire (technique de Orr-Loygue) chez 25 patientes.

Intractable constipation is frequently observed after rectopexy. The aim of our study was to look for clinical and manometric data, which could help to predict postoperative constipation. Twenty-five consecutive female patients treated by Orr-Loygue rectopexy were asked to answer a standard questionnaire and underwent anorectal manometry pre- and postoperatively. Nineteen patients complained of constipation after surgery. Preoperative constipation was significantly more frequent in patients who complained of postoperative constipation, than in patients who did not. Preoperative colonic transit time study in 8 patients was not useful in predicting postoperative constipation. Moreover, symptoms of constipation were quite similar pre- and postoperatively in the 19 patients complaining of postoperative constipation. Anorectal manometric data were not different between patients who complained of postoperative constipation and patients who did not. Therefore preoperative complaints of constipation are most important to consider before rectopexy.

[Treatment of acid gastroesophageal reflux by posterior hemifundoplication. Clinical and pH-metric results]. / Traitement du reflux gastro-cesophagien acide par hémifundoplicature postérieure. Résultats cliniques et pH-métriques.

The efficiency of posterior hemifundoplication (Toupet's procedure) in the treatment of gastroesophageal reflux was studied prospectively in 25 patients. Surgery was performed because of resistance to medical therapy and/or ulcerated esophagitis (12 cases). Clinical symptoms were evaluated three times: preoperatively, from 2 to 4 months after surgery and thirdly at a late post-operative interview (mean 21 months). Esophageal pH was recarded through a 3-h period after a standard meal and acid peptic reflux was expressed using a scoring index taking into account the duration and magnitude of pH fall. Esophageal pH was assessed in all the patients before and shortly after surgery and in 10 patients at the late postoperative control. Twenty-four of the 25 patients, had a dramatic improvement or were symptom-free, from 2 to 4 months after operation; the gastroesophageal reflux score decreased in all but 1 patient, but returned to physiological values in only 19 patients (group A), and remained above the normal range in 6 patients (group B). In the latter subjects, the preoperative score was significantly higher and the time elapsed below pH 3 significantly longer than those in group A. At the late postoperative control, clinical symptoms of gastroesophageal reflux were noted in 10 of the 23 patients interviewed. The incidence of late postoperative deterioration was more frequent in group B patients (4 among 6 subjects) than in group A (6 out of 17), and in patients presenting with severe esophagitis before surgery. In conclusion, while they confirm the immediate clinical efficiency of posterior hemifundoplication in gastroesophageal reflux, these results indicate that an abnormal esophageal pH test persists in 25 p. 100 of patients, and seems to carry an increased risk of further clinical deterioration.

[Analysis of different factors affecting results of the surgical treatment of gastroesophageal reflux]. / Analyse des différents facteurs conditionnant les résultats du traitement chirurgical du reflux gastrooesophagien.

Gastric emptying, gastric secretion and esophageal pH were studied prospectively in 32 patients who had either a Lortat-Jacob type operation (n = 7) or a fundoplication with a 360 degrees (n = 4), 270 degrees (n = 5) or 180 degrees (n = 16) gastric fundic wrap. The goal was to determine the effects of various antireflux mechanisms on these functions as well as to try to explain abnormal postoperative esophageal pH scoring indexes. Esophageal pH was recorded during the 3 h period following a standard meal. Acid reflux was expressed using a scoring index taking into account the duration and magnitude of pH fall. Preoperatively, all patients had an abnormal pH scoring index. Postoperatively, the pH scoring index remained increased in 7 patients (group A) and returned to normal values in 25 (group B). Clinical data, esophageal pH parameters and gastric acid secretion measured preoperatively were not significantly different in the two groups of patients. Preoperative gastric emptying for liquids was shorter in group A than in group B patients (p less than 0.05). Postoperative gastric emptying of radiopaque markers was not different in the two groups of patients. Postoperative resting pressure of the lower esophageal sphincter was always less than 10 cm H2O in group A and more than 10 cm H2O in group B patients. Changes in lower esophageal pressure after surgery were higher in group B than in group A patients (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of fecal incontinence in adults. Results as a function of clinical and manometric data and the importance of rehabilitation by biofeedback]. / Traitement de l'incontinence fécale de l'adulte. Résultats en fonction des données cliniques et manométriques, et intérêt de la rééducation par apprentissage instrumental.

Twenty-five females and 8 males, 20 to 83 year old, with fecal incontinence, normal rectal capacity and without evidence of active anorectal disease were studied in order to evaluate: a) the incidence of associated constipation; b) the anorectal motility pattern; c) the efficiency of treatment based on clinical data and anorectal motility disorders. Fifteen patients had constipation associated with fecal incontinence and 23 patients presented with at least one anorectal motility abnormality indicating biofeedback therapy. Compliance to therapy was poor since 9 patients did not accept the treatment; among the 24 subjects who accepted the treatment, 18 became continent and 5 were improved. These results were observed after treatment of constipation alone (6 cases) or associated with biofeedback therapy (5 cases), after biofeedback therapy (7 cases), and after surgery alone (3 cases) or followed by biofeedback therapy (2 cases). These results show that: a) constipation is frequently associated with incontinence in the adult; b) treatment of constipation, biofeedback therapy and surgery, used alone or combined according to clinical and anorectal motility data lead to good results in 75 p. 100 of patients.

[Sub-adventitial cystic degeneration of the popliteal artery. One case (author's transl)]. / La dégénérescence kystique sous-adventicielle de l'artère poplitée. A propos d'un cas.

On the basis of a new case of sub-adventitial cystic degeneration of the popliteal artery, the authors review the characteristics of this condition. The diagnosis may be suspected on the basis of clinical and arteriographic findings in an individual in whom the arterial system is otherwise normal. The various aetiological hypotheses are recalled. Treatment in the majority of cases consists of simple excision of the cyst. Intimal changes or segmental obstruction impose the need for resection with restoration of continuity by bypass.

[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.