Guideline compliance in bariatric surgery: a French nationwide study.

BACKGROUND: Strict adherence to guidelines with a comprehensive preoperative assessment and rigorous follow-up are essential to improve postoperative and long-term outcomes of bariatric surgery (BS). OBJECTIVES: To investigate the trends in BS in France and to assess the compliance to guidelines in people with obesity before and after BS. SETTING: University Hospital of Bordeaux, France. METHODS: Data on patients who were admitted for a primary BS procedure in France between January 1 and April 1, 2014, were extracted from the French national health insurance system database. Data on patients' characteristics, preoperative assessment, hospitalization, and postoperative follow-up, including medical consultations, laboratory tests, and drug consumption, during the year preceding and the 2 years after BS were collected. RESULTS: Most of the 11,824 patients (60.4%) had sleeve gastrectomy. Rates of reimbursement for preoperative consultations with general practitioners, digestive surgeons, and endocrinologists or internists were 94.5%, 89.2%, and 63%, respectively. Laboratory tests for nutritional and obesity-related co-morbidity evaluations were performed in 94.3% and 91.4%, respectively. Rates of consultation with general practitioners, digestive surgeons, and endocrinologists or internists dropped from 93.1%, 91.2%, and 29.2%, respectively, the first year to 88.4%, 50.3%, and 20%, respectively, the second year after BS (P < .001). Reimbursements for vitamin, iron, and calcium supplementation dropped from 66.6%, 24.9%, and 21%, respectively, the first year to 52.1%, 19.3%, and 11.7%, respectively, the second year after BS (P < .001). CONCLUSION: Overall compliance with guidelines is improving. While preoperative medical assessment is nearly optimal, efforts still should be made in order to improve long-term follow-up in general and patient adherence to micronutrient supplementation in particular.

Enteral versus parenteral nutrition in the conservative treatment of upper gastrointestinal fistula after surgery: a multicenter, randomized, parallel-group, open-label, phase III study (NUTRILEAK study).

BACKGROUND: Postoperative upper gastrointestinal fistula (PUGIF) is a devastating complication, leading to high mortality (reaching up to 80%), increased length of hospital stay, reduced health-related quality of life and increased health costs. Nutritional support is a key component of therapy in such cases, which is related to the high prevalence of malnutrition. In the prophylactic setting, enteral nutrition (EN) is associated with a shorter hospital stay, a lower incidence of severe infectious complications, lower severity of complications and decreased cost compared to total parenteral nutrition (TPN) following major upper gastrointestinal (GI) surgery. There is little evidence available for the curative setting after fistula occurrence. We hypothesize that EN increases the 30-day fistula closure rate in PUGIF, allowing better health-related quality of life without increasing the morbidity or mortality. METHODS/DESIGN: The NUTRILEAK trial is a multicenter, randomized, parallel-group, open-label phase III trial to assess the efficacy of EN (the experimental group) compared with TPN (the control group) in patients with PUGIF. The primary objective of the study is to compare EN versus TPN in the treatment of PUGIF (after esophagogastric resection including bariatric surgery, duodenojejunal resection or pancreatic resection with digestive tract violation) in terms of the 30-day fistula closure rate. Secondary objectives are to evaluate the 6-month postrandomization fistula closure rate, time of first fistula closure (in days), the medical- and surgical treatment-related complication rate at 6 months after randomization, the fistula-related complication rate at 6 months after randomization, the type and severity of early (30 days after randomization) and late fistula-related complications (over 30 days after randomization), 30-day and 6-month postrandomization mortality rate, nutritional status at day 30, day 60, day 90 and day 180 postrandomization, the mean length of hospital stay, the patient's health-related quality of life (by self-assessment questionnaire), oral feeding time and direct costs of treatment. A total of 321 patients will be enrolled. DISCUSSION: The two nutritional supports are already used in daily practice, but most surgeons are reluctant to use the enteral route in case of PUGIF. This study will be the first randomized trial testing the role of EN versus TPN in PUGIF. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03742752. Registered on 14 November 2018.

Cribriform-morular variant of papillary thyroid carcinoma: characteristic histologic feature of adenomatous polyposis. A case report.

We report the case of a 24-year-old woman with familial adenomatous polyposis and diagnosed with cribriform-morular variant of papillary thyroid carcinoma. Neck ultrasound and computed tomography identified multiple nodules in the thyroid gland and neck lymph nodes. The cytological analysis was compatible with the diagnosis of papillary cancer of the thyroid. Total thyroidectomy with lymph node dissection was performed. The histological analysis established the diagnosis of cribriform-morular variant of papillary thyroid carcinoma. Despite preoperative findings suggesting an aggressive form of thyroid cancer with lymph node involvement, the final diagnosis was a variant of papillary thyroid carcinoma often associated with familial adenomatous polyposis and known to have a good prognosis.