[Recent advances in digestive surgery]. / Nouvelles technologies en chirurgie digestive.

INTRODUCTION: Surgical practice in gastro-enterology is concerned by deep technological advances. In the past century, the technological advances were conducted by clinical challenges and strategies. The 21th century is clearly led by the inversion of the paradigms. Medical practice does not only depend on the access to the technologies, but it seems submitted to her. Should the physician follow the engineer ? Does the clinical data collection, depend on the computer ? Who decides ? The doctor, the patient or the Artificial Intelligence ? Materiel et Methods : The present essay that definitely does not answer all these questions, is achieved thanks the practical experience of our colleagues. We also collected the recent literature devoted to new and promising technologies. The PUBMED review is completed by several think tanks reports coming from the industry. RESULTS: Among the multiple aspects of present and future progresses, 6 among them could be pointed out: the benefit of augmented reality, mini and micro invasive techniques, robotic, news energies, big data and artificial intelligence. CONCLUSIONS: Progresses in data collection and treatment, imminent advances in micro mechanics, will completely change our clinical practice. The role of the doctor is in the center of this approach. We have to prepare young people to this human revolution.

INTRODUCTION: La pratique clinique gastro-entérologique chirurgicale vit de profonds bouleversements technologiques. Si le siècle passé consacrait l'amélioration des techniques diagnostiques et thérapeutiques au profit des procédures, des recommandations et des stratégies, le 21e siècle voit ce paradigme s'inverser. La médecine dépend non seulement de l'accès aux technologies mais depuis peu, elle s'y soumet. Le médecin doit-il suivre l'ingénieur ? La collecte des données dépend-elle de l'informaticien ? Qui décide ? Le praticien ? Le patient ? Ou l'intelligence artificielle ? Matériel et Méthodes : La présente réflexion, qui ne pourra pas répondre définitivement aux questions posées, s'alimente de la pratique quotidienne des chirurgiens de notre communauté. Nous avons collecté les articles et éditoriaux qui décrivent l'actualité technologique. Une revue dans PUBMED consacrée aux nouveautés technologiques en chirurgie digestive agrémentée de la recherche au sein des think tanks de l'industrie a permis d'en tirer les axes principaux. Résultats : Parmi la multitude de recherches et de progrès rapportés ou appliqués, 6 axes se dégagent : l'apport de l'imagerie en réalité augmentée, la mini ou micro invasivité, la robotique, les nouvelles énergies, les big data et l'intelligence artificielle. CONCLUSION: L'accélération des technologies de la collecte et du traitement de l'information couplée au progrès imminents en mécanique va révolutionner notre pratique clinique. Le rôle du médecin est complètement à réinventer. Il nous appartient de préparer les jeunes à cette révolution qui touche l'humanité.

[Strategy and critical analysis of bariatric surgery]. / Aspects stratégiques et analyse critique de la chirurgie bariatrique.

Bariatric surgery has considerably developed during the last 20 years in Belgium. The increase of prevalence of the morbid obesity and the development of multiple surgical procedures widened the spectrum of treatment. If a rigorous selection and a multidisciplinary approach of the patients are inescapable, the various decision-making algorithms plunge the practitioner into a certain confusion. The purpose of this paper is to clarify the advantages and the inconveniences of the different surgical treatments in light of the evolution of the principles and the objective results of the literature. Among the techniques proven and validated in the long run, one can mention the Silastic Ring Vertical Gastroplasty according to Mac Lean by minilaparotomy, the laparoscopic adjustable ring and the more recent gastric by pass. The evaluation of laparoscopic sleeve gastrectomy, and of duodenal switch is on course. The bilio-pancreatic by-pass according to Scopinaro remains strongly controversed. A meta-analysis of the literature confirms the success of the gastric bypass. Regarding to the long term follow-up, the adjustable gastric banding deceives. The sleeve gastrectomy should be analyzed in the long term. The preliminary results of a epidemiologic and financial study within a private hospital of Brussels reveals that the cost effective ratio is in favor the Silastic Ring Vertical Gastroplasty and the laparoscopic adjustable banding, as well in terms of public health support than the charge for the private insurance and the patient. The projection beyond 5 years reverses the tendency to plead in favor of the gastric by-pass. First with the hit-parade of comfort, food diversification, tolerance, gastro-esophageal reflux, and undoubtedly of the rate of recurrence, it supplants the others techniques for sweet eaters. The volume eaters can profit from a sleeve gastrectomy which undoubtedly supplants the Silastic Ring Vertical Gastroplasty responsible for late annular stenoses and reccurences.

Nissen versus Toupet fundoplication: results of a randomized and multicenter trial.

BACKGROUND: Laparoscopic Toupet fundoplication (TF) is reported to be as effective as Nissen (NF), but to be associated with fewer unfavorable postoperative side-effects. This study evaluates the one- and three-year clinical outcome of 140 randomized patients after a laparoscopic NF or TF. PATIENTS AND METHODS: Inclusion criteria included patients over 16 years old with complications of gastro-oesophageal reflux disease (GORD) and persistence or recurrence of symptoms after three months of treatment. Subjects with a previous history of gastric surgery or repeated fundoplication, brachy-oesophagus or severe abnormal manometry results were excluded. Seventy-seven NF and 63 TF were performed. The severity of symptoms was assessed before and after the procedure. RESULTS: One hundred and twenty-one of the 140 patients after one year, and 118 after three years, were evaluated and no statistically significant clinical difference was observed. The level of satisfaction concerning the outcome of the operation remained high after one or three years regardless of the type of fundoplication performed. CONCLUSIONS: Functional complications after NF are not avoided with TF.

Results of silastic ring vertical gastroplasty more than 6 years after surgery: analysis of a cohort of 214 patients.

BACKGROUND: Among the different techniques of surgical treatment for morbid obesity, silastic ring vertical gastroplasty (SRVG) is an alternative, effective and easily reproducible technique. The aim of this study is to evaluate a cohort of patients >6 years after SRVG for morbid obesity. METHODS: From 1991 to 1996, 273 consecutive patients were eligible for SRVG. The evaluation criteria included weight loss, evolution of co-morbidities, long-term morbidities, satisfaction of patients and quality of life. RESULTS: Among these 273 patients, 1 patient died in the postoperative period (0.4%). Postoperative morbidities occured in 27 patients (10%). The long-term follow-up involved 213 patients (78%). Late postoperative complications consisted of outlet stoma stenosis (14%), staple-line dehiscence (5.6%) and incisional hernia (8.5%). 23 patients (10%) needed a re-do operation. Co-morbidities drastically improved. BMI fell from 45.3 to 30.7. Failure of SRVG was statistically associated with male gender and super-obese patients. 69% of the patients were satisfied, and 73% would recommend this operation. CONCLUSION: SRVG is very effective in a selected group of morbidly obese patients.

Biliary pleural fistula as a complication of radiofrequency ablation for liver metastasis.

Radiofrequency ablation (RFA) recently emerged as an efficient and safe local ablative method to treat unresecable liver tumours. Currently however, the full spectrum of potential complications of RFA remains undetermined. We report a case of severe biliary complication, associating main bile duct stricture and biliary pleural fistula, arising after extensive RFA for unresectable liver metastasis of central location. Treatment consisted of external drainage of the pleural effusion and internal endoscopic drainage via a biliary stenting. This description of a life-threatening complication emphazises the need to better knowledge of the contraindications of RFA, particularly for the treatment of large tumours at proximity of main bile ducts.

[Surgical strategy in rectosigmoidal cancer]. / Stratégie chirurgicale dans le cancer rectosigmoidien.

Colorectal cancer is frequent and diagnosed earlier thanks to the screening and to the progresses in the preoperative assessment. The precocity of the surgical resection takes advantage from the complete resection of vascular and nodes involvement. The rectal localisation of the cancer requires to take the reconstruction into account. If preoperative radiotherapy is helpful in T4 and T3 N2 and locally advanced tumour, the surgeon should consider the four approaches of rectal cancer: the anterior resection (Dixon-Wangensteen) (DW) with total mesorectal excision (TME), the colo-anal anastomosis with a J pouch, the abdomino-perineal approach (Miles procedure) requiring a definitive left colostomy, and in some rare cases the transanal local resection.

What did the laparoscopic Nissen approach of the gastro-oesophageal reflux really change for the patients 8 years later?

BACKGROUND: Nissen fundoplication (NF) is recognized as the surgical treatment of the gastro-oesophageal reflux disease (GERD). NF can be achieved either by open surgery or by laparoscopic approach. METHODS: From 1987 to 1997, 210 patients were treated for GERD by NF: 61 by open and 149 by laparoscopic approach. All the patients were followed more than 1 year and were scored by clinical assessment (Visick scale adaptation). In case of Visick score > 1, GI-endoscopy, X-ray series or 24-hour pH-study complete the evaluation. RESULTS: The operative time was comparable between both groups. The postoperative recovery was statistically faster in the laparoscopic group (p = 0.0001). The mean time of follow-up was 6 years after open NF and 4 years after laparoscopic NF. After open NF or laparoscopic NF, 72% and 67% of the patients are respectively scored Visick 1, 13% and 21%--Visick 2, 6.8% and 6%--Visick 3 and 8.2% and 6%--Visick 4 (NS). Patients with recurrence of GERD were scored Visick 4, so failure of the surgical treatment is observed in 5 patients after open NF and 9 patients after laparoscopic NF. The occurrence of incisional hernia was significantly higher in the open group (p = 0.0001). CONCLUSION: NF remains a safe procedure for surgical treatment of GERD and can be achieved by laparoscopic approach with comparable results to those by open laparotomy. In our experience, the advantages of the laparoscopic approach is a faster postoperative recovery and a lower risk of incisional hernia.

Ambulatory blood pressure and neuroendocrine control after diet-assisted gastric restrictive surgery.

BACKGROUND: Long-term weight control after conventional diet is disappointing but may be improved when diet is assisted by gastric restrictive surgery (GRS). OBJECTIVE: To determine the effects of GRS on ambulatory blood pressure (ABP) and neuroendocrine BP control in 28 morbidly obese subjects. METHODS: A BP and heart rate were recorded every 10 min for 25 h before and 4 months after GRS. Effects of marked reductions in body weight on the renin-angiotensinaldosterone system, on plasma insulin and on sympathetic activity were also determined. RESULTS: Body mass index decreased from 43 +/- 1 to 34 +/- 1 kg/m2 and systolic (S) BP decreased by 7 +/- 2 mmHg during daytime (P=0.01) and by 8 +/- 3 mmHg during the night (P=0.02). Pulse pressure, a marker of reduced arterial compliance, decreased by 5 +/- 1 mmHg throughout the 24 h period (P < 0.001). Diastolic BP remained unchanged. Heart rate decreased more during the night (-13 +/- 2 bpm, P<0.0001) than during daytime (-5 +/- 2 bpm, P=0.03). Reductions in SBP were largest in subjects with highest initial BP values (r = -0.63, P<0.001) but were unrelated to weight loss. GRS decreased fasting glycaemia, plasma insulin, plasma C peptide and 24 h urine sodium (n=20) and noradrenaline (n=19) excretion (P<0.01). CONCLUSIONS: Diet-assisted GRS favourably affects neuroendocrine BP control in obese patients. Reductions in sodium intake, insulin levels and sympathetic tone combined with possible improvements in arterial compliance induce persistent 24 h reductions in SBP and pulse BP. Reductions in BP are largest in subjects with highest initial BP values and are unrelated to the amount of weight loss, thereby emphasizing the importance of even moderate reductions in weight on BP control.

Diversion of intestinal flow decreases the numbers of interleukin 4 secreting and interferon gamma secreting T lymphocytes in small bowel mucosa.

BACKGROUND/AIMS: The intestinal immune system faces large amounts of antigens, and its regulation is tightly balanced by cytokines. In this study, the effect of intestinal flow diversion on spontaneous secretion of interleukin (IL)-4 and interferon (IFN)- gamma was analysed. METHODS: Eight patients (two with Crohn's disease, four with ulcerative colitis, and two with previous colon cancer) carrying a double lumen small bowel stoma after a total colectomy procedure were included in the study. For each patient, eight biopsy samples were taken endoscopically from both the diverted and non-diverted part of the small bowel. Intraepithelial lymphocytes (IELs) and lamina propria lymphocytes (LPLs) were isolated separately and assayed for numbers of cells spontaneously secreting IL-4 and/or IFN-gamma by an ELISPOT technique. RESULTS: Compared with the non-diverted mucosa, a significant decrease in the number of spontaneously IFN-gamma secreting CD3 lymphocytes was observed in the diverted small bowel mucosa among both IELs (p = 0.008) and LPLs (p = 0.007). The same results, although less significant, were obtained for IL-4, especially in LPLs (p = 0.01). CONCLUSION: The intestinal content influences the spontaneous secretion of IFN-gamma and IL-4 by intestinal lymphocytes. These results could help to elucidate the anti-inflammatory role of split ileostomy in patients suffering from inflammatory bowel diseases.

[Cap polyposis: a rare syndrome]. / Cap polyposis: un syndrome rare.

We report a case of inflammatory cap polyposis of the colon, a rare syndrome, affecting the rectosigmoid. It was observed in a context of mucous diarrhea. Endoscopic and radiological features consisted of elevated and umbilicated nodular lesions. Histology revealed polypoid lesions containing elongated crypts with superficial abrasions, covered by inflammatory and fibrinoid material. Etiopathogenesis of this new syndrome is unknown.

Contribution of computed tomography to decision making in the management of adhesive small bowel obstruction.

BACKGROUND: In adhesive small bowel obstruction, the early recognition of complications such as strangulation or volvulus is essential to choose between surgical or conservative initial treatment. The objective of this study was to determine prospectively the contribution of computed tomography (CT) to decision making in the management of these patients. METHODS: Patients with suspected adhesive small bowel obstruction had CT at admission. Patients with CT signs of volvulus or strangulation and/or clinical signs of peritoneal irritation underwent urgent surgery; other patients had conservative initial treatment. RESULTS: Fifty-four patients were evaluated. CT demonstrated signs of strangulation or volvulus in 19 patients, including three with signs of peritoneal irritation. Within this group, urgent laparotomy was performed in 17 patients and confirmed the CT diagnosis in 16. Thirty-seven patients without clinical or CT signs of complications had initial conservative treatment; among them, seven of 12 with a distal obstruction determined by CT required a delayed operation for persisting obstruction, compared with two of 25 patients with a proximal obstruction (P < 0.01). CONCLUSION: CT is useful for the evaluation of adhesive small bowel obstruction, to detect accurately patients with complications who require urgent operation and to determine the location of the adhesion, which represents a significant prognostic factor for success of conservative treatment.

The place of upper gastrointestinal tract endoscopy before and after vertical banded gastroplasty for morbid obesity.

In industrialized countries, surgical gastroplasty is performed more and more frequently in patients with morbid obesity. The aims of this prospective study were to determine the incidence of upper gastrointestinal lesions in obese patients and to assess the place of digestive endoscopy in symptomatic patients after gastroplasty. A consecutive group of 159 obese patients were studied before and after vertical banded gastroplasty. In the preoperative evaluation, reflux esophagitis and gastroduodenal lesions were endoscopically observed in 31% and 37% of the patients, respectively. Interestingly, the majority of the obese patients with upper gastrointestinal lesions were asymptomatic. In the postoperative follow-up period, 55 of the 159 patients complained of upper gastrointestinal symptoms such as vomiting (72%), esophageal reflux (17%), and epigastric pain (3%). Stenosis of the outlet of the gastric pouch was described in 40 of the 55 symptomatic patients. Esophagitis was observed in 60% of these patients. Endoscopic dilation using Savary bougies or TTS balloon was successfully performed in all the patients with symptomatic stenosis of the gastric outlet. Food impaction was endoscopically removed in four patients. Thus, we recommend performing an upper gastrointestinal endoscopy in obese patients who are candidates for surgical gastroplasty because of the high incidence of upper gastrointestinal peptic lesions. Endoscopy is also helpful in patients with digestive disorders occurring after gastroplasty in order to define and to treat the lesions.

The cognitive, subjective, and physical effects of a ginkgo biloba/panax ginseng combination in healthy volunteers with neurasthenic complaints.

We evaluated the effects of a Ginkgo biloba/ginseng combination on cognitive function in this 90-day, double-blind, placebo-controlled, parallel-group study. Sixty-four healthy volunteers (aged 40 to 65 years), selected on the basis of fulfilling the ICD-10 F48.0 criteria for neurasthenia, were assigned randomly to four equal dosing groups, receiving 80, 160, or 320 mg of the combination b.i.d. or placebo. Assessments were performed on the day before dosing, and again at Days 1, 30, and 90 at 1 hour after the morning dose and 1 hour after the afternoon dose. The assessments included the Cognitive Drug Research (CDR) computerized assessment system, the Vienna Determination Unit, cycle ergometry, and various questionnaires. The treatments were well tolerated by all volunteers. On Day 90 at 1 hour post morning dosing, dose-related improvements were seen on the CDR tests, the 320 mg dose being significantly superior to placebo. These effects, however, were reversed 1 hour after the afternoon dose, possibly suggesting that a longer inter-dosing interval would be preferable. The 80-mg dose produced a significant benefit on the ergometry assessment of heart rate at maximum load. There were also several supporting changes from other assessments, including an advantage of 320 mg over placebo on the global score from the Symptom Checklist-90-revised (SCL-90-R) at Day 90.

[The treatment of morbid obesity with gastroplasty]. / Traitement de l'obésité morbide par gastroplastie.

Morbid obesity is related to a severe decrease in life expectancy. No medical or dietary treatment offers an alternative to control hypertension, apnea syndrome, orthopedic diseases, ..., caused by overweight. With respect to a serious preoperative evaluation and a severe selection (psychologic, dietetic, ...) Silastic Ring Vertical Gastroplasty is considered in our experience (more than 300 cases) and in the literature as the gold standard for surgical treatment of obesity. The long term follow-up (24-66 months) of 100 consecutive operated patients shows a positive response on hypertension (96%), apnea syndrome (92%), diabetes (85%), gastroesophageal reflux (76%), orthopedic diseases (74%) and cardiorespiratory insufficiency (74%). Considering our experience in the medical and surgical management of patients operated in our department or referred from other centers for complications after different procedures, we actually propose SRVG as the treatment of choice for morbid obesity.

[Post-gastroplasty plastic surgery]. / La chirurgie plastique post-gastroplastie.

Gastric volume modification by surgery (gastroplasty, gastric banding ...) is intended to improve health in patients presenting morbid obesity. However, consecutive cutaneous sequellae are always ungrateful and often particularly disabling. The treatment of these sequellae often necessitates plastic surgery correction. We present a series of 21 patients whose cutaneous sequellae secondary to gastroplasty were operated on after a mean loss of 42% of body mass index. Sixty-three anatomical sites were treated in 27 operative sessions without any general complication. The number of operative sessions was limited using a simultaneous multiple surgical team approach, which is particularly adapted to this type of patients. The local complications (11 cases) were minor (delays of healing, hematoma, seroma, abscess). Even though the final aesthetic appearance depended greatly on the preoperative situation, all the patients were satisfied with the results obtained.