Diagnostic of hepatic fibrosis with the XL probe of the Fibroscan versus biopsies in patients candidates to bariatric surgery.

BACKGROUND AND AIMS: The risks of the histological evaluation for metabolic liver disease in severe obese subjects led to the development of the Fibroscan® device. The main objective of our study is to evaluate the diagnostic performance of XL probe for the measurement of hepatic fibrosis compared to histological examination, in obese subjects operated from bariatric surgery. METHODS: We included patients free from chronic liver diseases. Liver measurement and controlled attenuation parameter (CAP) were carried out using the Fibroscan®. Liver biopsies were performed during bariatric surgery and evaluated by two pathologists. Correlation between vibration-controlled transient elastography (VCTE) and fibrosis stage was assessed using the Kendall correlation coefficient. Diagnosis performance was assessed using receiver-operating-characteristic curve analysis together with its 95% confidence interval. Cut-off value maximizing the Youden index was computed together with specificity, sensitivity, positive and negative predictive values. RESULTS: The average age and body mass index were 41 years and 43 kg/m2, respectively (n = 108). Forty-one percent of patients presented fibrosis on the histological results. The Kendall correlation coefficient between fibrosis stage and liver stiffness measurement (LSM) was κ = 0.33, p<10-5. ROC analysis for the detection of fibrosis indicated the following values: 0.70 [0.60-0.79] for F≥1, 0.83 [0.72-0.92] for F≥2, 0.90 [0.83-0.97] for F≥3. Optimal cut-offs maximizing the Youden index were 7.0 kPa for F≥1, 8.1 kPa for F≥2 and 8.7 kPa for F≥3. CONCLUSION: Fibroscan® appears to be reliable for detection of significant and severe fibrosis in severe obese patients such as candidates for bariatric surgery. CLINICAL TRIAL NUMBER: NCT03548597.

Inter-mesenteric connections between the superior and inferior mesenteric arteries for left colonic vascularization: implications for colorectal surgery.

PURPOSE: There is confusion regarding the names, the number, and the exact location of the colonic arterial arches which provide connections between the superior and inferior (IMA) mesenteric arteries at the level of the left colic angle. The aim of this review was to delineate the "true" colic arches arising in the meso of the left colic angle and to describe their surgical implications. METHODS: A systematic review of the literature was performed using the MEDLINE database. The search included only human studies between 1913 and 2018. All dissection, angiographic, arterial cast and corrosion studies were analyzed. RESULTS: The terms "Riolan arch", "marginal artery of Drummond", "meandering mesenteric artery" and "Villemin's arch" must no longer be used in the scientific literature. Three arterial arches were found at the level of the left colic angle, permitting the communication between the two arterial mesenteric systems: (1) the Marginal Artery (the most peripheral, found in 100% of cases); (2) the "V" termination of the ascending branch of the left colic artery (LCA), existing in more than 2/3 of cases; and (3) the inter-mesenteric trunk, found more centrally located and existing in less than 1/3 of cases. CONCLUSIONS: Three arterial arches exist at the level of the left colic angle: (1) the Marginal Artery, (2) the "V" termination of the ascending branch of the LCA, and (3) the inter-mesenteric trunk. The knowledge of this anatomy is essential for performing colorectal surgeries involving ligation of the IMA.

Comparison of complete versus partial mesh removal for the treatment of chronic mesh infection after abdominal wall hernia repair.

PURPOSE: Treatment of chronic mesh infections (CMI) after parietal repair is difficult and not standardized. Our objective was to present the results of a standardized surgical treatment including maximal infected mesh removal. METHODS: Patients who were referred to our center for chronic mesh infection were analyzed according to CMI risk factors, initial hernia prosthetic cure, CMI characteristics and treatments they received to achieve a cure. RESULTS: Thirty-four patients (mean age 54 ± 13 years; range 23-72), were included. Initial prosthetic cure consisted of 26 incisional hernias and eight groin or umbilical hernias of which 21% were considered potentially contaminated because of three intestinal injuries, two stomas and two strangulated hernias. The mesh was synthetic in all cases. CMI appeared after a mean of 83 days (range 30-6740) and was characterized by chronic leaking in 52 cases (50%), an abscess in 22 cases (21%) and synchronous hernia recurrence in 17 cases (16.5%). Eighty-six reinterventions were necessary, including 36 mesh removals (42%), and 13 intestinal resections for entero-cutaneous fistula (15%). The CMI persistence rate was 81% (35 reinterventions out of 43) when mesh removal was voluntarily limited to infected and/or not incorporated material, but was 44% when mesh removal was voluntarily complete (19 reinterventions out of 43; p < 0.001). On average, 3.4 interventions (1-11) were necessary to achieve a cure, after 2.8 years (0-6). Fourteen incisional hernia recurrences occurred (41%). CONCLUSIONS: Treatment of chronic mesh infection is lengthy and resource-intensive, with a high risk of hernia recurrence. Maximal mesh removal is mandatory.

Esophageal tissue engineering: Current status and perspectives.

Tissue engineering, which consists of the combination and in vivo implantation of elements required for tissue remodeling toward a specific organ phenotype, could be an alternative for classical techniques of esophageal replacement. The current hybrid approach entails creation of an esophageal substitute composed of an acellular matrix and autologous epithelial and muscle cells provides the most successful results. Current research is based on the use of mesenchymal stem cells, whose potential for differentiation and proangioogenic, immune-modulator and anti-inflammatory properties are important assets. In the near future, esophageal substitutes could be constructed from acellular "intelligent matrices" that contain the molecules necessary for tissue regeneration; this should allow circumvention of the implantation step and still obtain standardized in vivo biological responses. At present, tissue engineering applications to esophageal replacement are limited to enlargement plasties with absorbable, non-cellular matrices. Nevertheless, the application of existing clinical techniques for replacement of other organs by tissue engineering in combination with a multiplication of translational research protocols for esophageal replacement in large animals should soon pave the way for health agencies to authorize clinical trials.

Management of voluminous abdominal incisional hernia.

Incisional hernia is one of the classic complications after abdominal surgery. The chronic, gradual increase in size of some of these hernias is such that the hernia ring widens to a point where there is a loss of substance in the abdominal wall, herniated organs can become incarcerated or strangulated while poor abdominal motility can alter respiratory function. The surgical treatment of small (<5 cm) incisional hernias is safe and straightforward, by either laparotomy or laparoscopy. For large hernias, surgical repair is often difficult. After reintegration of herniated viscera into the abdominal cavity, the abdominal wall defect must be closed anatomically in order to restore the function to the abdominal wall. Prosthetic reinforcement of the abdominal wall is mandatory for long-term successful repair. There are multiple techniques for prosthetic hernia repair, but placement of Dacron mesh in the retromuscular plane is our preference.

Functional disorders and quality of life after esophagectomy and gastric tube reconstruction for cancer.

Functional disorders such as delayed gastric emptying, dumping syndrome or duodeno-gastro-esophageal reflux occur in half of the patients who undergo esophagectomy and gastric tube reconstruction for cancer. The potential role for pyloroplasty in the prevention of functional disorders is still debated. Antireflux fundoplication during esophagectomy can apparently reduce the reflux but at the cost of increasing the complexity of the operation; it is not widely used. The treatment of functional disorders arising after esophagectomy and gastroplasty for cancer is based mainly on dietary measures. Proton pump inhibitors have well documented efficiency and should be given routinely to prevent reflux complications. Erythromycin may prevent delayed gastric emptying, but it should be used with caution in patients with cardiovascular disorders. In the event of anastomotic stricture, endoscopic dilatation is usually efficient. Problems related to gastrointestinal functional disorders after esophageal resection and gastric tube reconstruction do not significantly impair long-term quality of life, which is mainly influenced by tumor recurrence.

[Comparison of quality of life in morbidly obese patients and healthy volunteers. A prospective study using the GIQLI questionnaire]. / Qualité de vie des patients obèses relevant d'un traitement chirurgical comparée à celle d'une population témoin. Etude prospective utilisant le questionnaire GIQLI.

BACKGROUND: Morbid obesity decreases the quality of life. The aims of surgical and medical treatment are weight loss, reduction of co-morbidity, and improved quality of life. AIMS: To compare the quality of life between obese patients (BMI: 40 or>35+comorbidity) and healthy volunteers using the GIQLI (Gastrointestinal Quality of Life) questionnaire. PATIENTS: Between January 2001 and December 2002, 127 morbidly obese patients (109 female, 18 male) with a mean age of 40.1 years were surgically treated with laparoscopic gastric banding. Quality of life, as measured by the GIQLI questionnaire, was systematically evaluated pre-operatively. During the same period, a control group of 125 healthy volunteers of comparable age, gender, and prior surgical history were evaluated using the same questionnaire. RESULT: The two groups, while comparable in age and gender, were significantly different in terms of weight (123 vs. 66 kg), BMI (44.3 vs. 22.2) (p<0.001), co-morbidity factors (p=0.001), and professional activity (p=0.02). The mean global GICLI score was 122 for healthy individuals and 95 for morbidly obese patients. (p=0.001), and the differences were most marked in the super obese. These differences particularly involved social dysfunction, physical status, and emotional symptoms but were not significantly different for gastrointestinal symptoms. CONCLUSION: The quality of life in morbidly obese and super obese patients is significantly diminished from that of a control population. There was good correlation between the degree of obesity (BMI) and the alteration of the GIQLI global and subscales scores. Quality of life should be systematically evaluated before and after both medical and surgical therapy.