Failure to eradicate Helicobacter pylori infection is more frequent among HIV-positive patients.

OBJECTIVES: Helicobacter pylori is a worldwide infection, but little is known about the efficacy of treatment for H. pylori infection in HIV-positive patients. The goal of this work was to evaluate outcomes after first-line H. pylori treatment and identify risk factors for failure in HIV-positive patients. METHODS: This registry study of unmatched H. pylori-infected HIV-positive patients and HIV-negative obese pre-bariatric surgery controls was performed in a tertiary university hospital. Cases were enrolled from 2006 to 2017, controls from 2007 to 2014, and both received standard of care. An additional 'optimal' subgroup of cases was enrolled prospectively from 2017 to 2019 which was treated only on the basis of antibiogram, drug interaction search and additional support by one referent physician. Helicobacter pylori eradication failure rates were compared according to clinical, microbiological and pathological parameters and treatment. RESULTS: We analysed 258 HIV-positive patients and 204 HIV-negative control patients. Helicobacter pylori eradication failure rates were markedly greater in cases (24.1%) than in controls (8.8%). The proportions of levofloxacin and metronidazole resistance were greater in cases than in controls (P < 0.05). Among cases treated with H. pylori triple therapy (S3T), the 'optimal' subgroup experienced a 9.5% failure rate vs. 28.6% with other strategies (P = 0.01). Risk factors for failure were H. pylori treatment strategy, exposure to antiretroviral treatment, and alcohol status. Overall, positive HIV status was a risk factor for S3T eradication failure. CONCLUSIONS: Patients co-infected with H. pylori and HIV frequently failed to eradicate H. pylori and this was related to treatment strategy, antiretroviral exposure and lifestyle.

First 200 consecutive transumbilical single-incision laparoscopic TEPs.

BACKGROUND: Endoscopic pre-peritoneal mesh repair (TEP) through single-incision laparoscopy (SIL) permits placement of a large mesh through a final millimetric umbilical scar. This prospective study evaluates the first 200 consecutive SILTEPs performed by a single surgeon. PATIENTS AND METHODS: Between November 2011 and September 2015, 200 consecutive SILTEPs were performed in 161 patients. The mean age was 49.8 ± 16.3 years and the mean BMI was 24.5 ± 3.4 kg/m2. The technique involved one 11-mm trocar, one 10-mm 0° scope and curved reusable instruments. A supplementary 1.8-mm straight trocarless grasping forceps was percutaneously inserted for perioperative complications or difficulties. RESULTS: A unilateral hernia repair was performed in 122 patients, and a bilateral repair in 39 patients. The total operative time was 57.4 ± 22.3 min, and pure laparoscopic time was 46.6 ± 21.6 min. There was no need for insertion of a supplementary 5-mm trocar, and the need for insertion of 1.8-mm trocarless grasper was 32.9%. Perioperative complications occurred in 73 patients. The mean final scar length was 15.3 ± 2.6 mm. The mean hospital stay was 1.0 ± 0.3 days. Postoperative complications at the access site affected 15 patients and at the hernia site 31 patients. After a mean follow-up of 25.4 ± 12.3 months, there was one asymptomatic, small incisional hernia at the access site as well as one reoperation for recurrent inguinal hernia at 16 months. No other late complications were registered. CONCLUSION: Transumbilical SILTEP permits placement of a large mesh through a final millimetric scar. Getting over the learning curve in conventional multitrocar TEP is mandatory. As per our institute's algorithm, the contraindications continue to be giant inguino-scrotal, incarcerated and recurrent inguinal hernias.

Colorectal anastomotic leakage corrected by transanal laparoscopy.

AIM: Interest in transanal laparoscopy has increased in the last decade. This approach can allow primary procedures such as polypectomy, total mesorectal excision and the treatment of postoperative complications such as bleeding, leakage and fistula formation. METHOD: Two patients treated by transanal repair for leakage of a colorectal anastomosis after laparoscopic anterior resection of the rectum are reported. The first developed leakage immediately during the surgery and in the second leakage presented at 4 weeks. A new transanal platform according to DAPRI (Karl Storz-Endoskope, Tuttlingen, Germany), formed by a reusable port and reusable monocurved instruments was developed to permit manipulation of sutures introduced via the anus in a maximally ergonomic manner. Laparoscopic suturing was performed transanally and a protective ileostomy was added as well. RESULTS: The transanal procedures took 60 and 45 min and the patients were discharged after 5 days and 2 days. At 2 months both defects were found to be healed on contrast radiology and endoscopy; therefore the ileostomy was closed. Anal function was satisfactory with a frequency of two and one times per 24 h with no incontinence or evidence of sepsis. CONCLUSION: Intra-operative or late leakage of colorectal anastomosis can be safely treated by transanal laparoscopy. This new transanal platform offers the surgeon the possibility to work in ergonomic positions, without increasing the cost of the procedure thanks to the reusable nature of the material used.

Randomised clinical trial: transoral incisionless fundoplication vs. sham intervention to control chronic GERD.

BACKGROUND: Until recently only two therapeutic options have been available to control symptoms and the esophagitis in chronic gastro-oesophageal reflux disease (GERD), i.e. lifelong proton pump inhibitor (PPI) therapy or anti-reflux surgery. Lately, transoral incisionless fundoplication (TIF) has been developed and found to offer a therapeutic alternative for these patients. AIM: To perform a double-blind sham-controlled study in GERD patients who were chronic PPI users. METHODS: We studied patients with objectively confirmed GERD and persistent moderate to severe GERD symptoms without PPI therapy. Of 121 patients screened, we finally randomised 44 patients with 22 patients in each group. Those allocated to TIF had the TIF2 procedure completed during general anaesthesia by the EsophyX device with SerosaFuse fasteners. The sham procedure consisted of upper GI endoscopy under general anaesthesia. Neither the patient nor the assessor was aware of the patients' group affiliation. The primary effectiveness endpoint was the proportion of patients in clinical remission after 6-month follow-up. Secondary outcomes were: PPI consumption, oesophageal acid exposure, reduction in Quality of Life in Reflux and Dyspepsia and Gastrointestinal Symptom Rating Scale scores and healing of reflux esophagitis. RESULTS: The time (average days) in remission offered by the TIF2 procedure (197) was significantly longer compared to those submitted to the sham intervention (107), P < 0.001. After 6 months 13/22 (59%) of the chronic GERD patients remained in clinical remission after the active intervention. Likewise, the secondary outcome measures were all in favour of the TIF2 procedure. No safety issues were raised. CONCLUSION: Transoral incisionless fundoplication (TIF2) is effective in chronic PPI-dependent GERD patients when followed up for 6 months. Clinicaltrials.gov: CT01110811.

[Evolution of low back pain after bariatric surgery]. / Evolution des douleurs lombaires après chirurgie bariatrique.

Although frequently called to mind by physicians, the relationship between overweight and low back pain is poorly understood and remains controversial. The present study aims to evaluate the evolution of low back pain in 65 patients planned for a bariatric surgery. The patients were enrolled prospectively. 54 patients (80%) could be evaluated 5 months after the procedure, and 47 patients (72%) were evaluated 22 months after surgery. Mean weight loss was 19 ± 9 kg (P < 0.001) at 22 months post-op. Patients demonstrated a statistically significant improvement of the NRS, Oswestry and SF-36 scores. This study suggests that low back pain might be reduced following bariatric surgery. However, the lack of dose-response effect is against a causal relationship between low back pain and obesity. Larger randomised controls are needed to determine a causal relationship.

Single-access laparoscopic primary and incisional prosthetic hernia repair: first 50 patients.

BACKGROUND: Primary and incisional hernia can be repaired by multitrocar laparoscopy. Single-access laparoscopy (SAL) recently gained interest to decrease the invasiveness and to reduce the abdominal trauma, besides improved cosmetic results. The authors report first 50 patients who consulted for primary and incisional hernia and treated by SAL prosthetic repair. PATIENTS AND METHODS: Between December 2009 and March 2012, 50 patients (24 females, 26 males) were submitted to SAL for primary (23) and incisional hernia (27). Mean age was 49.1 ± 15.1 years (17-75), and mean body mass index 29.7 ± 5.7 kg/m(2) (19-44.1). A total of 26 primary and 30 incisional hernias were treated. The technique consisted in implied the use of an 11-mm trocar for 10-mm scope, curved reusable instruments without trocars, and dualface prosthesis fixed by tacks without transfascial closures. RESULTS: No conversion to open surgery nor addition of one or more trocars was necessary. Mean perioperative hernia sizes were 7.0 ± 5.0 cm (2-24) in length and 6.0 ± 3.4 cm (1-16) in width, for a surface of 55.0 ± 64.6 cm(2) (2.8-268.2). Mean prosthesis size used was 188.1 ± 113.4 cm(2) (56.2-505.6). Mean laparoscopic time was 60.2 ± 32.8 min (26-153), and mean final scar length was 21.2 ± 4.5 mm (13-35). Mean hospital stay was 2.2 ± 1.2 days (1-8). Perioperative complications were registered in 4 patients and minor early complications in 13 patients of each group. After a mean follow-up of 16.1 ± 8.8 months (4-34), 2 late complications were observed in one patient of each group. CONCLUSION: Primary and incisional hernia can safely be treated by SAL prosthetic repair, but a learning curve is unavoidable. Thanks to this approach, in patients with primary hernia, only a small scar is finally visible, and in patients who proved to be prone to develop incisional hernia, the number of fascial incisions can be reduced.

Laparoscopic conversion of Roux-en-Y gastric bypass to biliopancreatic diversion.

BACKGROUND: This report describes the laparoscopic conversion of a Roux-en-Y gastric bypass (RYGBP) to biliopancreatic diversion (BPD). CASE REPORT: In January 1995, a 47-year-old woman with a body mass index (BMI) of 54 kg/m(2) benefited from a silicon ring vertical banded gastroplasty (SRVBG) for morbid obesity. She showed significant weight loss and reached a BMI of 30 kg/m(2). After 7 years, she experienced weight regain (BMI, 34.5 kg/m(2)), so a laparoscopic conversion to RYGBP was proposed. The patient again had a successful weight loss (BMI, 26 kg/m(2)), but 6 years later, she mentioned a weight regain (BMI, 33 kg/m(2)) with invalidating retrosternal pain. The nutritionist's analysis of the patient showed a certain modification of the alimentary character with frequent meals (grazing/polyphagia), and the psychologist's consultation identified an important binge-eating disorder. A laparoscopic conversion of RYGBP to BPD was proposed. The procedure consisted of (1) adhesiolysis and reduction of a hiatal hernia, (2) sectioning of the gastric pouch proximally to the gastrojejunostomy, (3) resection of the fundus of the gastric remnant excluded by the previous SRVBG, (4) restoration of the continuity of the stomach between the gastric pouch and the gastric remnant, (5) resection of the gastric antrum and pylorus, (6) deconstruction of the previous jejunojejunostomy, (7) restoration of the continuity of the small bowel, (8) measurement of the new common and alimentary limbs and construction of the jejunoileostomy, (9) closure of the mesenteric defect, (10) construction of the gastroileostomy, (11) closure of Petersen's space, and (12) repair of the hiatal hernia followed by a leak test. RESULTS: The operative time was 320 min, and the blood loss was 380 ml. The patient had an uneventful recovery and was discharged on postoperative day 5. Her BMI was 30.5 kg/m(2) after 3 months and 26 kg/m(2) after 6 months. The barium swallow showed good transit through the gastrointestinal tract. CONCLUSIONS: The laparoscopic conversion of RYGBP to BPD is technically feasible and effective during the short term for cases of repeated weight regain.

Ivor Lewis esophagectomy with manual esogastric anastomosis by thoracoscopy in prone position and laparoscopy.

INTRODUCTION: Only a few authors have reported the technique of Ivor Lewis esophagectomy by minimally invasive means, and anastomosis was usually performed by a circular stapler. We report an Ivor Lewis esophagogastrectomy with manual esogastric anastomosis performed by thoracoscopy in the prone position. CASE REPORT: An adenocarcinoma of the distal esophagus without lymph nodes invasion was diagnosed in a 51-year-old man. General anesthesia and double-lumen endotracheal tube intubation were used. First the patient was placed in the supine position, and five abdominal trocars were placed. Celiac lymphadenectomy was performed with section of the left gastric vessels. A wide Kocher maneuver and pyloroplasty were performed. A wide gastric tube was performed and advanced through the hiatus into the right chest. Subsequently the patient was placed in the prone position. Three trocars (two 5-mm and one 11-mm) were placed on the posterior axillary line in the fifth, seventh, and ninth right intercostal space. The intrathoracic esophagus was dissected. Mediastinal lymphadenectomy with en bloc resection of the left inferior mediastinal pleura was performed. The azygos vein was sectioned, and the esophagus was transected by scissors 1-cm cranial to the azygos vein. A completely thoracoscopic manual double-layer anastomosis was performed by using running sutures with PDS 2/0 externally and Maxon 4/0 internally. Finally the patient was replaced in the supine position to retrieve the specimen through a suprapubic incision, and the gastric tube was fixed to the hiatus. RESULTS: Thoracoscopy lasted 157' (anastomosis 40'), laparoscopy 160', and second laparoscopy 20'. Blood loss was estimated at 170 ml. The gastrograffin swallow on postoperative day 4 showed absence of stenosis and leak. The patient was discharged on postoperative day 6. CONCLUSIONS: Thoracoscopy in the prone position allows the surgeon to perform a thoracoscopic esogastric anastomosis completely handsewn without selective lung desufflation, and using only three trocars.

A laparoscopic approach to left diaphragmatic rupture after blunt trauma.

Diaphragmatic rupture after blunt trauma is rare, but indicates a powerful external impact. Associated lesions are often life-threatening and require a rapid diagnosis and management. We report a case of a 24-year-old man, admitted to the emergency department after a serious car accident. He complained of a left sided thoraco-abdominal pain with breathing difficulties. Chest X-ray showed a left diaphragmatic elevation. Computed tomography demonstrated a left haemo-pneumothorax, herniation of the stomach in the chest and a haemoperitonium. Laparoscopically, herniated organs were re-integrated in the abdominal cavity ; the diaphragmatic tear was repaired by both direct suture and synthetic prosthesis. Closure of a small bowel perforation found during the laparoscopic exploration was also performed. We consider this therapeutic modality to be an excellent approach in the management of acute left side diaphragmatic rupture in haemodynamically stable patients. Firstly, it permits an inspection of the thoracic cavity through the diaphragmatic tear and secondly, an easy repair of damaged structures in the abdominal cavity.

Video. Laparoscopic transgastric access to the common bile duct after Roux-en-Y gastric bypass.

INTRODUCTION: Rapid weight loss after Roux-en-Y gastric bypass (RYGBP) often is associated with gallstones formation, which can lead to cholecystitis and/or choledocholithiasis. Difficult access to the biliary tract is one of the disadvantages after RYGBP. We report a useful technique of laparoscopic transgastric access to the gastric remnant for an endoscopic retrograde cholangiopancreatography (ERCP). CASE REPORT: A 40-year-old woman with a BMI of 48 kg/m(2), was submitted to a laparoscopic RYGBP in December 2003. At that time the abdominal ultrasound was negative for gallbladder lithiasis. In April 2007, she was admitted for upper right side abdominal pain, vomiting episodes, fever, and jaundice; the BMI at the time was 24 kg/m(2). Hepatic ultrasound showed lithiasis of the common bile duct with intra- and extrahepatic bile duct dilation, as well as gallbladder lithiasis. The patient was taken to the operating room for laparoscopic evaluation. A pursestring suture was performed on the greater curvature of the gastric remnant. After the opening of the stomach, an 18-mm trocar was inserted into the lumen and the endoscope was directly passed through the port into the duodenum. An ERCP was performed under fluoroscopic guidance, and as a result of sphincterotomy the stone was retrieved. After removing the endoscope, the gastrotomy was closed by tying the pursestring. Cholecystectomy was performed as well. RESULTS: The procedure lasted 98 min. Liver function tests returned normal on postoperative day 2, and the patient was discharged on postoperative day 4. After 9 months, the patient was well and asymptomatic. CONCLUSIONS: Patients previously submitted to RYGBP and presenting choledocholithiasis can benefit from an ERCP through the gastric remnant.

A delayed Boerhaave's syndrome diagnosis treated by thoracoscopy in prone position.

Boerhaave's syndrome or postemetic rupture of the esophagus, carries a high morbidity and mortality. The authors report a delayed Boerhaave's syndrome diagnosis (3 days), successfully treated by right thoracoscopic debridement in prone position. Thanks to gravity the cardiopulmonary bloc drops back and the access to the esophagus is direct allowing for accurate placement of the chest tubes near the perforation. The procedure is completed by laparoscopic placement of a feeding jejunostomy with the patient supine.

Minimally invasive esophagectomy for cancer: laparoscopic transhiatal procedure or thoracoscopy in prone position followed by laparoscopy?

BACKGROUND: Minimally invasive esophagectomy is rapidly emerging as a suitable surgical alternative to the open technique. This retrospective comparative study aimed to compare two minimally invasive techniques for esophagectomy: transhiatal laparoscopy with intrathoracic or cervical anastomosis (group A) and right thoracoscopy in prone position followed by laparoscopy and left cervicotomy (group B) performed by the same surgeon (G.B.C.). The operative time, perioperative blood loss, intensive care and total hospital stays, peri- and postoperative morbidity, in-hospital mortality, number of lymph nodes dissected, and survival were the outcome measures. METHODS: Between April 1999 and August 2005, 24 patients (group A) and 15 patients (group B) underwent minimally invasive esophagectomy for cancer in the authors' department. Their median age was 61 years in group A and 61 years in group B. Preoperatively, the endoscopic location of the tumor was in the upper third in 2 cases (1 vs 1), the middle third in 11 cases (7 vs 4), and the lower third in 26 cases (16 vs 10). Two patients in each group received neoadjuvant chemo- and radiotherapy. One patient (group A) and two patients (group B) received only neoadjuvant chemotherapy, and three patients (group A) received only neoadjuvant radiotherapy. RESULTS: The median operative time was 300 min (range, 240-420 min) in group A and 377 min (range, 240-540 min) in group B (nonsignificant difference [NS]). The median perioperative bleeding was 325 ml (range, 100-800 ml) in group A and 700 ml (range, 100-2,400 ml) in group B (NS). The perioperative complications included one splenectomy in each group and one conversion to thoracotomy in group B. The postoperative medical complications totaled three in group A and six in group B. The postoperative surgical complications included one hemoperitoneum, one pneumothorax, five anastomotic leaks, and two recurrent laryngeal nerve paralyses in group A and two tracheal necroses, four anastomotic leaks, one colic fistula, and three recurrent laryngeal nerve paralyses in group B. The median intensive care unit (ICU) stay was 5 days (range, 2-70 days) for group A and 5 days (range, 1-180 days) for group B (NS). The median hospital stay was 12 days (range, 7-98 days) for group A and 14 days (range, 7-480 days) for group B (p = 0.05). The early mortality rate was 0%. All the specimens were free of disease. The median number of mediastinal/periesophageal lymph nodes was 3 (range, 1-10) for group A and 4 (range, 2-13) for group B (NS), and the median number of celiac/perigastric lymph nodes was 11 (range, 2-31) for group A and 10 (range, 3-22) for group B (NS). After a median follow-up period of 42.4 months (range, 2-84 months) for group A and 19.1 months (range, 1.5-34 months) for group B, 12 patients in group A died after a median period of 22 months (range, 2-55 months), and 7 patients in group B died after a median time of 15 months (range, 1.5-23 months). CONCLUSIONS: This retrospective comparative study showed that minimally invasive esophagectomy performed by thoracoscopy in the prone position is comparable with laparoscopic transhiatal esophagectomy in terms of the significant postoperative and survival outcomes.