Prospective, multicentric, comparative study between sleeve gastrectomy and Roux-en-Y gastric bypass, 277 patients, 3 years follow-up.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en Y gastric bypass (LRYGB) are commonly performed, but few studies have shown superiority of one strategy over the other. OBJECTIVE: Simultaneously compare LSG and LRYGB in terms of weight loss and morbimortality over a 36-month follow-up period. SETTING: University hospital and bariatric surgery centers, France. METHODS: Prospective, comparative study between LSG and RYGBP. The primary endpoint of this study was a joint hypothesis during the 36-month follow-up: the first primary outcome pertained to the frequency of patients with an excess weight loss (EWL) greater than 50% (% EWL>50%) after LSG or RYGB; the second primary outcome was defined as a composite endpoint of at least one major complication. Secondary objectives were regression of comorbidities and improvement in quality of life. RESULTS: Two hundred and seventy-seven patients were included (91 RYGBP, 186 LSG). The mean age was 41.1±11.1 years, and average preoperative body mass index of 45.3±5.5kg/m2. After 36months, the %EWL>50% was not inferior in the case of LSG (82.2%) relative to LRYGB (82.1%); while major complications rates were significantly higher in LRYGB (15.4%) vs. LSG (5.4%, P=0.005). After 36months, all secondary objectives were comparable between groups while only gastroesophageal reflux disease (GERD) increased in LSG group and decreased in LRYGB group. CONCLUSIONS: LSG was found non-inferior to LRYGB with respect to weight loss and was associated with lower risk of major complications during a 3-year follow-up. But GERD increased in LSG group and decreased in LRYGB group.

[Nephro-uretero-sigmoidectomy for colonic carcinoma associated with destruction of kidney after ureterosigmoidostomy: a case report]. / Néphro-urétéro-sigmoïdectomie pour cancer colique avec destruction rénale après urétéro-sigmoïdostomie: à propos d'un cas.

A patient underwent at his birth, an ureterosigmoidostomy for exstrophic bladder. Fifty-six years later, she presented a carcinoma on the right ureterosigmoidostomy associated with chronic urinary infection. She underwent a right ureteronephrectomy and sigmoidectomy. Chronic alterations of the colic mucin by urines lead to carcinoma.

Right hepatectomies without vascular clamping: report of 87 cases.

BACKGROUND/PURPOSE: Portal triad clamping and total or intermittent hepatic vascular exclusion are usually used to reduce blood loss during major liver resections. We report, in this retrospective study, the results of right hepatectomy without vascular clamping. METHODS: From January 1986 to July 2001, 87 right hepatectomies, including 14 extended right hepatectomies, were performed without vascular clamping. There was 53 men and 34 women, with a mean age of 60.2 +/- 12.5 years. Indications were 58 metastases, 16 hepatocellular carcinomas, 5 cholangiocarcinomas, 4 adenomas, 3 angiomas, and 1 carcinoid tumor. All the procedures were carried out using an ultrasonic dissector and intraoperative ultrasonography with only vascular control (looping of the hepatic pedicle and supra; and infrahepatic vena cava). RESULTS: There were four postoperative deaths and 23 complications (26%), including hepatocellular failure (6), pulmonary complications (6), transient bile leakage (5), digestive bleeding (2), subphrenic abscess (1), inferior vena cava (IVC) thrombosis (1), disseminated intravascular coagulation (DIC; 1), and evisceration (1). Forty-two patients (48%) had no blood transfusion. The mean blood transfusion requirement was 1.5 +/- 2.7 units. The mean operative length was 280 +/- 60 min and the mean hospital stay was 12.8 +/- 8.1 days. Liver function test results were similar to those in other studies on days 1, 4, and 7 postoperatively, with a return to normal values after 1 week. CONCLUSIONS: In our experience with major liver resections, vascular clamping is not necessary.

[Composite, non-resorbable parietal prosthesis with polyethylene terephtalate-polyurethane (HI-TEX PARP NT): prevention of intraperitoneal adhesions. Experimental study in rabbits]. / Prothèse pariétale composite et non résorbable en polyéthylène téréphtalate-polyuréthane (HI-TEX PARP NT): prévention des adhérences intrapéritonéales. Etude expérimentale chez le lapin.

The authors report an experimental study in the rabbit with a new composite non absorbable mesh in Polyethylene Terephtalate-Polyurethane used for incisional hernia repair in intraperitoneal positioning. This new mesh has one permeable side in polyethylene terephtalate for rapid tissue fixation and another side in polyruethane, hydrophob in order to avoid cell penetration. Eighteen rabbits were operated. A wound was created in aponeurose, muscle and peritoneal abdominal wall. The mesh was placed in intraperitoneal positioning and was taken off at 4, 9 and 13 months for histologic examination and electronic microscopical examination. Tolerance, adhesion, tissular reaction and neoperitoneum formation have been studied. All the meshes were well integrated and without sepsis. In 18% of cases small and monocclusive intraperitoneal adhesions were found. This new composite mesh in intraperitoneal positioning gave good results at medium-term in the rabbit. It's an attractive alternative for incision hernias repair with intraperitoneal mesh.

[Portal hypertension in a patient with hepatitic C revealing an iatrogenic arterioportal fistula]. / Hypertension portale chez un malade porteur d'une hépatite C, révélatrice d'une fistule artérioportale iatrogène.

A 67-year-old man with anti-HCV positive serum, was admitted for hematemesis by variceal bleeding. Portal hypertension, which initially was thought to be caused by a post-hepatitis C cirrhosis, was due to a fistula between a right hepatic artery and a right branch of the portal vein. The fistula located under the right liver and the adjacent atrophic hepatic segments, were resected by a bi-segmentectomy VI-VII. The postoperative course was simple. The pathological study of the resected liver showed no cirrhosis but active hepatitis. This arterioportal fistula was probably iatrogenic. Sixteen years before, this patient had undergone a total gastrectomy for cancer, followed by a serious haemorrhage requiring a massive transfusion, which was responsible for the transmission of hepatitis C.

[Video-guided retrosternoscopy: a new approach in retrosternal esophagoplasty]. / La "vidéorétrosternoscopie", une nouvelle approche dans l'oesophagoplastie rétrosternale.

In this study, the authors described a new videoscopically guided approach for tunneling in esophagoplasty and insertion of an esophageal prosthesis.

[Mesenteric serous cysts. Report of 2 cases]. / Kystes séreux du mésentère. A propos de deux cas.

Two cases of mesenteric serous cysts were reported. The first was a 65 years old woman who underwent laparotomy for abdominal pain associated with a mass initially thought to be ovarian. The second cyst was also an incidental discovery in a 59 years old female during abdominal computed tomography for thrombocytopenia. After surgical resection the first woman was well, 7 months and the second lady 4 years later, without recurrence. The two were unilocular serous cysts. By reporting these two observations, the authors aimed to show the rarity of the mesenteric serous cysts in a succint clarification on the disease.

Early experience with laparoscopic approach for solid liver tumors: initial 16 cases.

OBJECTIVE: To evaluate the feasibility and outcome of laparoscopic hepatectomy in patients with solid liver tumors. SUMMARY BACKGROUND DATA: Although the laparoscopic approach has become popular in the surgical field, the value of laparoscopy in liver surgery is unknown. METHODS: Fifteen patients with solid liver tumors underwent 16 consecutive laparoscopic resections at the authors' institution between 1994 and 1999. Indications were symptomatic hemangioma, focal nodular hyperplasia, liver cell adenoma, isolated metastasis from a colon cancer, and hepatocellular carcinoma. The laparoscopic procedure was performed using four to seven ports (four 10-mm, two 5-mm, and one 12-mm). RESULTS: One patient underwent a major hepatic resection (right lobectomy); the others underwent minor hepatic resections (left lateral segmentectomies, IVb subsegmentectomies, segmentectomy, and nonanatomical excisions). The laparoscopic procedure was uneventful in 15 patients; one patient required conversion to open laparotomy because of inadequate free surgical margins. CONCLUSION: Laparoscopic surgery of the liver is feasible. The use of this new technical approach offers many advantages but requires extensive experience in hepatobiliary surgery and laparoscopic skills. The authors' experience suggests that laparoscopic procedures should be reserved for benign tumors in selected cases. Its application must be verified by further studies.

[Laparoscopic treatment of solid and cystic tumors of the liver. Study of 33 cases]. / Traitement laparoscopique des tumeurs solides et kystiques du foie. Etude de 33 cas.

AIM OF THE STUDY: Laparoscopic liver surgery is still in its early stages. The aim of this study was to report our experience in the laparoscopic management of solid and cystic liver tumours. PATIENTS AND METHODS: From April 1991 to December 1999, 32 patients with various lesions of the liver underwent laparoscopic liver surgery. One group of patients presented with cysts (n = 15) (11 giant solitary cysts and 4 polycystic liver diseases) and one group of patients presented with solid tumours (n = 18): focal nodular hyperplasia (n = 8), haemangioma (n = 6), adenoma (n = 2), isolated metastasis from a colonic cancer (n = 1) and hepatocellular carcinoma (n = 1). Fifteen cyst fenestrations and eighteen liver resections were performed via a laparoscopic approach including 1 right lobectomy, 5 left lateral segmentectomies, 2 subsegmentectomies IVb, 1 segmentectomy III and 9 non-anatomical resections. RESULTS: Conversion to laparotomy was performed in one case (3%) at the end of the operation (patient who had successfully undergone left lateral segmentectomy for hepatocellular carcinoma) to check the resection margins and surgical transection had been performed in healthy parenchyma. Mean diameter of solid tumours was 6.5 cm and 15.7 cm for solitary cysts. The mean operating time for hepatic resections was 232 minutes. There was no postoperative mortality. Complications occurred in one case for each group and consisted in intestinal stricture through a port site requiring intestinal resection. Mean postoperative hospital stay was 5.6 days for solid tumours and 7.5 days for cystic lesions. In the group of cystic lesions, the recurrence rate was 50% with a 5.5-months follow-up. CONCLUSION: Laparoscopic liver surgery can be safely performed, but requires a good experience in open hepatic surgery and laparoscopic surgery. The laparoscopic approach is indicated in patients with symptomatic or atypical benign solid tumour, giant solitary cyst and polycystic liver disease, located anteriorly on the liver. Indications for malignant lesions have not been clearly defined and require further information.

The value of fibrin sealant in thyroid surgery without drainage.

Fibrin sealant is widely used to achieve complete hemostasis in many fields of surgery. A retrospective review of the surgical management of 81 patients with thyroid diseases between 1992 and 1998 was undertaken to determine if drainage after thyroid surgery could be safely avoided and substituted by fibrin sealing before closure of the wound. Complications were few and resulted in one patient with hoarseness, four minor oedemas and one case of unexplained fever during 48 h. The subjective discomfort from the collar incision was unusual and aesthetic healing was obtained in most of the cases (93.8%). These results suggest that the application of fibrin sealant can be advocated in thyroid surgery as an adjunct to a good surgical procedure and perhaps that prophylactic drainage is unnecessary.

[Ruptured hepatocarcinoma. Report of 22 cases]. / Les hépatocarcinomes rompus. A propos de 22 cas.

STUDY AIM: Spontaneous rupture of hepatocellular carcinoma (HCC) causing massive hemoperitoneum is a critical and life threatening complication. The study aim was to report a retrospective series of 22 cases observed in the same centre. PATIENTS AND METHODS: From 1978 to 1998, 22 patients (18 males and four females, mean age: 63 years, range: 18-83) were treated for ruptured H.C.C involving a cirrhotic liver in 17 cases and a normal liver in five cases. In 14 cases, the diagnosis of acute hemoperitoneum indicated an immediate laparotomy. The site of rupture was predominant in the left lobe (eight cases). The surgical treatment was: left lobectomy (n = 7), right hepatectomy (n = 2), excision (n = 4), hepatic artery ligation (n = 5), direct hemostasis (n = 4). RESULTS: Postoperative mortality was 45.4%. Among the 12 survivors, nine died within a delay of 6 to 29 months. Three patients were still alive at the time of this study at 32, 40 and 66 months. CONCLUSION: Acute rupture of HCC requires emergency procedures with a high risk of mortality. Curative operation with hepatic resection is the most effective procedure but is not often feasible because of the spreading of the tumor or/and the cirrhosis. The ligation of hepatic artery seems to be an alternative procedure to obtain an immediate hemostasis. Fissuration allows performance of complementary explorations and possibly preoperative arterial embolization with better immediate results.

[Limits of laparoscopic surgery of adrenal glands. Apropos of 17 cases and a review of the literature]. / Limites de la résection coelio-chirurgicale des surrénales. Dix-sept observations et revue de la littérature.

OBJECTIVES: To review own cases of laparoscopic adrenalectomy in order to better ascertain limits therapeutic management and indications, compared with the literature data. PATIENTS-METHODS: Medical files of 15 patients after 17 laparoscopic adrenalectomies in the Dupuytren hospital of Limoges from February 1994 to November 1996, were analyzed 10 women and 5 men mean aged 59.4 years (22-77) were operated. Transperitoneal laparoscopic adrenal resection indications were: Conn adenoma (3), Cushing discase (2 bilateral resection), adrenal incidentaloma (9) and adrenal metastasis (1). RESULTS: Mean (range) of adrenal tumor size was 4 cm (0.8-7.5 cm). Operating times mean (range) was: 3 hours 40 minutes (1 h 50-6 h). Mean (range) of hospital stay was 3.4 day (3-6), marquedly reduced than open traditional adrenal surgery. Neither complication nor mortality per- or post-operative were present. But the laparoscopic operation required conversion to an open adrenal resection in 3 cases (18%). COMMENTS: Laparoscopic adrenalectomy offer real advantages: effectiveness and safety with a reduced time hospital discharge. Indications and adrenal size limits need to be precised on largest studies.

[Primary adenocarcinoma of the duodenum. Study of three cases and review of the literature]. / Adénocarcinome primitif du duodénum. Etude de trois observations et revue de la littérature.

The authors report three cases of primary adenocarcinoma, two concerning the duodenum and the third concerning the duodenojejunal junction. These rare tumours are characterized by polymorphic and non specific clinical signs. Diagnosis is suspected by upper gastrointestinal fibroscopy and barium swallow, and confirmed by biopsies. Prognosis varies according to histological differentiation and lymph node extension. Whipples operation is the sole curative procedure in the absence of local lymph node involvement. Cases of extensive invasion are managed by bilio-digestive by-pass.

[Total gastrectomy and viscerosynthesis]. / Gastrectomies totales et viscérosynthèse.

A retrospective study of 134 total gastrectomies performed between 1982 and 1992 was conducted with regular follow-up. There were 96 males and 38 women (mean age 66.66 years, range 27-82). The indication for total gastrectomy was malignant tumour (n = 115), mostly adenocarcinoma (79.1%, 91/115) with 7 cases of stump degeneration after partial gastrectomy (5.2%) and benign lesions (n = 19), mostly gastric ulcers. Gastrectomy was associated with node dissection in 53 cancer cases (47.8% 53/115) and dissection of neighbouring organs in 16 patients. Y anastomosis with circular mechanical suture was performed in 78 cases (62.9%) with pre-stapling in 30 (38.5%). Operative mortality was 8.2% (11/134). The oesophagealjejunal disunion occurred in 7/133 patients (5.3%) including two fatal cases. Early reoperation was necessary in 10.5%. Long-term follow-up for 2 to 12 years in 119 patients gave the following data. For malignant tumours: 5-year survival rate 10.1% (n = 8), recurrence an anastomosis 6.3% (n = 5), distant recurrence 28.2% (n = 21). For all patients sequellae were: reflux oesophagitis 8.1% (n = 10), stenosis of the anastomosis 7.3% (n = 9) requiring late reoperation in 2. The quality of life was considered satisfactory by 28.57% (n = 8) and good in 39.29% (n = 11). These results were compared with those reported in the literature and led to the conclusion that the general view as to the gravity of gastrectomy should be reconsidered in light of the progress in viscerostapling.