Long-term endoscopic follow-up after sleeve gastrectomy.

BACKGROUND: Endoscopic follow-up after sleeve gastrectomy (SG) sometime reveals worrisome findings as the presence of major digestive lesions such as esophagitis, Barrett's esophagus (BE), and also esophageal cancer. OBJECTIVES: The aim of this study was to investigate the frequency and severity of esophageal and gastric lesions after SG. METHODS: Our team collected the results of esogastric endoscopies performed on patients who underwent SG up to five years before in our hospital, from April 2010 to August 2014. Summons were sent by mail to all patients operated on between those dates. The results were collected from January 2018 to June 2019. RESULTS: Of the 765 patients who underwent SG up to five years before, only 78 (10.2%) agreed to undergo an upper digestive endoscopy. The average age before surgery was 51 years (range: 25-70 years). The mean preoperative body mass index (BMI) was 44.2±4.6kg/m2. For 12 out of these 78 patients (15.4%) it was revisional surgery: 9 SG after gastric banding, and 3 revisional SG (Re-SG). With an average follow-up of 6.3±0.8 years, the endoscopic results of the 78 patients were found to be normal in 31 cases (39.7%): gastritis was found in 28 patients (35.9%), severe grade C or D esophagitis was found in 15 cases (19.2%), hiatal hernia in 18 cases (23.1%), a benign gastric polyp in 2 cases (2.6%). Of the 28 patients with gastritis, HelicobacterPylori was detected in 8 cases (28.6%). No cancer was diagnosed, and BE after SG was found in only one case (1.3%) (normal before surgery). Six of 15 patients with esophagitis (40%) had reflux symptoms. Fourteen of these patients (93.3%) developed de novo esophagitis. CONCLUSION: Only 10.2% of operated patients agreed to a long-term esogastric endoscopy. The frequency and severity of endoscopic anomalies observed with an average follow-up of more than 6 years pleads for a policy of systematic upper endoscopies of long-term control after SG.

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.

Treatment of Leaks Following Sleeve Gastrectomy by Endoscopic Internal Drainage (EID).

BACKGROUND: Leaks are considered one of the major complications of laparoscopic sleeve gastrectomy (LSG) with a reported rate up to 7 %. Drainage of the collection coupled with SEMS deployment is the most frequent treatment. Its success is variable and burdened by high morbidity and not irrelevant mortality. The aim of this paper is to suggest and establish a new approach by endoscopic internal drainage (EID) for the management of leaks. METHODS: Since March 2013, 67 patients presenting leak following LSG were treated with deployment of double pigtail plastic stents across orifice leak, positioning one end inside the collection and the other end in remnant stomach. The aim of EID is to internally drain the collection and at the same time promote leak healing. RESULTS: Double pigtails stent were successfully delivered in 66 out of 67 patients (98.5 %). Fifty patients were cured by EID after a mean time of 57.5 days and an average of 3.14 endoscopic sessions. Two died for event not related to EID. Nine are still under treatment; five failure had been registered. Six patients developed late stenosis treated endoscopically. CONCLUSIONS: EID proved to be a valid, curative, and safe mini-invasive approach for treatment of leaks following SG. EID achieves complete drainage of perigastric collections and stimulates mucosal growth over the stent. EID is well tolerated, allows early re-alimentation, and it is burdened by fewer complications than others technique. Long-term follow-up confirms good outcomes with no motility or feeding alterations.

Five-year results of sleeve gastrectomy.

OBJECTIVE: Our purpose was to evaluate the efficacy and safety of sleeve gastrectomy (SG) at 5 years after surgery. PATIENTS AND METHODS: From June 2005 to January 2007, 65 obese patients underwent SG. The percentage of excess weight loss (%EWL) and excess BMI loss (% EBL), obesity-related co-morbidities, and post-SG complications were evaluated at 2 years after SG based on our database, and at 5 years after SG based on a questionnaire sent to the patients by one of the authors (IB) between May 2011 and February 2012. RESULTS: A complete data set was obtained for 53 of 65 patients (82%), including 45 patients who had SG as the only surgical treatment, and eight patients who had a second bariatric procedure at a later date because of insufficient weight loss (five gastric bypass (GBP), three SG revision). For these 53 patients, the mean %EWL was 54.4% at 2 years and 53.7% at 5 years, and the mean %EBL was 61% at 2 years and 60% at 5 years. Three patients (5.7%) had post-operative complications (two fistulas (3.8%), one hemorrhage (1.9%)). Three trocar-site hernias (5.7%) were observed between 10 months and 34 months post-SG. Sub-group analysis of the 45 patients who underwent SG alone showed a mean %EWL of 57.1% at 2 years and 50.7% at 5 years; the mean %EBL was 64% at 2 years and 56.8% at 5 years. Of these 45 patients, 13 (28.9%) required medication to treat diabetes (DM) before SG and only five (11.1%) at 5 years after SG (61.5% decrease); 18 (40%) had antihypertensive treatment before SG, and eight (17.8%) at 5 years after SG (55.5% decrease); 12 (26.7%) took lipid-lowering medication before SG, and five (11.1%) at 5 years after SG (58.3% decrease); 24 (53.3%) had sleep apnea (SAS) before SG and six (17.8%) at 5 years after SG (75% decrease). However, while only five patients (11.1%) had GERD requiring PPI therapy before SG, 15 patients required PPI therapy (33.3%) at 5 years after SG (200% increase). CONCLUSION: Five years after performance of SG, weight loss was satisfactory, few complications were observed, the reduction of co-morbidities was significant, but there was an increase in the frequency of GERD.

Weight loss after sleeve gastrectomy in super superobesity.

Objective. This prospective study evaluated laparoscopic sleeve gastrectomy for its safety and efficiency in excess weight loss (%EWL) in super superobese patients (BMI >60 Kg/m(2)). Results. Thirty patients (33 women and 7 men) were included, with mean age of 35 years (range 18 to 59). Mean preoperative BMI was 66 Kg/m(2) (range 60 to 85). The study included one patient with complete situs inversus and 4 (14%) with previous restrictive gastric banding. The mean operative time was 120 minutes (range 80 to 220 min) and the mean hospital stay was 7.5 days (4 to 28 days). There was no postoperative mortality or need for a laparotomy conversion. Two subphrenic hematomas, one gastric fistula, and one pulmonary embolism, were the major complications. After 18 months 17 (77%) had sufficient weight loss and six had insufficient results, leading to either re-sleeve gastrectomy (3), or gastric bypass (2). Three years after the initial laparoscopic sleeve gastrectomy, the mean EWL was 51% (range 21 to 82). Conclusion. The laparoscopic sleeve gastrectomy is a safe and efficient operating procedure for treating super superobesity. In the case of insufficient weight loss, a second-stage operation like resleeve gastrectomy or gastric bypass can be proposed.

[Longitudinal sleeve gastrectomy as a stand-alone bariatric procedure: Results of a multicenter retrospective study]. / La gastrectomie longitudinale (sleeve gastrectomy) comme unique chirurgie bariatrique : résultats d'une étude rétrospective multicentrique de 446 patients.

INTRODUCTION: Sleeve gastrectomy as an isolated procedure is a new option in bariatric surgery. The aim of this study was to evaluate its short and medium term (2 years) results in a multicenter setting. MATERIALS: This is a retrospective study including 446 patients undergoing surgery in 14 teaching, private, and public hospitals. RESULTS: The immediate post-operative course were uneventful in 83.3% of patients. Minor complications occurred in 10.9% of patients and major complications in 5.3%. Suture line leaks occurred in 4.3% of the whole series. There was no mortality and the rate of reoperation was 2%. Overall mean weight loss after two years was 32 kg and the mean excess weight loss was 62%. Weight loss was significantly greater in non super-obese patients (p=0.0003). CONCLUSIONS: This study confirms the feasibility of sleeve gastrectomy in a multicenter setting; it is efficacious at two years as an isolated bariatric procedure for non super-obese patients. It is possible that an additional second-stage procedure may be necessary for super-obese patients.

Laparoscopic ultrasonography is a complement to cholangiography for the detection of choledocholithiasis at laparoscopic cholecystectomy.

BACKGROUND: Intraoperative cholangiography and laparoscopic ultrasonography are both used in the detection of common bile duct stones at laparoscopic cholecystectomy. The aim of this prospective study was to determine whether laparoscopic ultrasonography has an alternative or a complementary role with respect to cholangiography in achieving this end. METHODS: The biliary trees of 900 patients undergoing laparoscopic cholecystectomy were examined routinely by the two methods. The diagnostic power of each investigation and of the two techniques in combination was evaluated. The statistical non-random concordance between the two methods was also determined. RESULTS: Laparoscopic ultrasonography was performed in all 900 patients. Cholangiography was performed in 762 (85 per cent). The mean (range) duration was 9.8 (4-21) min for laparoscopic ultrasonography and 17.6 (7-42) min for cholangiography. For the detection of common bile duct stones, with a kappa coefficient of 0.57 (95 per cent confidence interval (c.i.) 0.43 to 0.71), the non-random concordance between the two methods was considered to be fair to good. The sensitivity of laparoscopic ultrasonography was 0.80 (95 per cent c.i. 0.65 to 0.91) and its specificity was 0.99 (95 per cent c.i. 0.98 to 1.00). The respective values for cholangiography were 0.75 (95 per cent c.i. 0.59 to 0.87) and 0.99 (95 per cent c.i. 0.98 to 1.00). The examinations combined had a sensitivity of 0.95 (95 per cent c.i. 0.86 to 0.99) and a specificity of 0.98 (95 per cent c.i. 0.96 to 1.00). CONCLUSION: Laparoscopic ultrasonography and intraoperative cholangiography are complementary, as the combination of both methods maximizes the intraoperative detection of choledocholithiasis.

[Quality of life one year after laparoscopic fundoplication is close to that of a control group: prospective study]. / La qualité de vie un an après fundoplicature laparoscopique est proche de celle d'un groupe témoin: étude prospective.

AIM OF THE STUDY: Prospective evaluation of the quality of life of patients after laparoscopic fundoplication for gastroesophageal reflux disease (GERD). PATIENTS AND METHODS: The quality of life of 30 consecutive patients who underwent laparoscopic fundoplication was evaluated using the GIQLI (gastrointestinal quality of life index) questionnaire, which included 36 items in five different areas: digestive symptoms, physical condition, emotional reaction, social integration and medical treatment. Seventeen men and 13 women (mean age: 50.2 +/- 17 years (32-68) were included with a follow-up of at least 1 year and with complete data available. The quality of life was evaluated before surgery, and at 1 month, 3 months, 6 months and 1 year after surgery with a 100% follow-up. Thirty healthy volunteers representing an identical population (with respect to age, sex, BMI, profession, smoking, etc.) anonymously filled in the same questionnaire. The pre- and postoperative GIQLI scores of patients operated for GERD were compared with the GIQLI score of the control group. RESULTS: Preoperatively, the GIQLI score (87 +/- 9.5) was much lower than that of the control group (123.4 +/- 13.6) (p < 0.001). This score significantly improved 3 months and 1 year after surgery and was comparable to that of the healthy population (115.3 +/- 9.6 vs 123.4 +/- 13.6 [ns]). Improvements were reported mainly with respect to digestive symptoms and physical condition. Social integration was slightly modified. CONCLUSION: The quality of life of patients after laparoscopic antireflux surgery was greatly improved and was close to the level expected in an healthy population. However, the study demonstrated the possible presence of postoperative functional digestive disorders, although these symptoms were not considered as being uncomfortable, since the level of satisfaction was 96.6% (n = 29).

Quality of life 2 years after laparoscopic total fundoplication: a prospective study.

This study was a prospective evaluation of the quality of life of 50 patients after laparoscopic total fundoplication surgery for gastroesophageal reflux disease. The quality of life of 50 consecutive patients who underwent laparoscopic total fundoplication was evaluated using the Gastrointestinal Quality of Life Index questionnaire, which included 36 items in five different areas: symptoms, physical well-being, psychologic well-being, social relationships, and effects of medical treatment. Twenty-seven men and 23 women with a mean age of 52.6 +/- 16 years (range, 31-68 years) with gastroesophageal reflux disease were treated by laparoscopic total fundoplication (Nissen-Rosetti) and were included in the study. The follow-up was at least 2 years after surgery. The quality of life was evaluated before the surgery and 1 month, 3 months, 6 months, 1 year, and 2 years after surgery with follow-up in 100% of the cases. A control group of 50 healthy volunteers representing an identical population to that of the patients operated on (with respect to age, sex, body mass index, profession, and smoking) anonymously completed the same questionnaire. The preoperative and postoperative Gastrointestinal Quality of Life Index questionnaire scores of patients who had laparoscopic total fundoplication were compared with the Gastrointestinal Quality of Life Index questionnaire scores of the control group. Before surgery, the Gastrointestinal Quality of Life Index questionnaire score (86.7 +/- 8.5) was much inferior to that of the control group (123.8 +/- 13.6) (P < 0.001). This score significantly improved 3 months after surgery and was comparable (not significant) to that of the healthy control population 3 months, 6 months, 1 year, and 2 years after surgery (119.3 +/- 7.8). Improvements were reported mainly with respect to gastrointestinal symptoms and physical well-being. Social relationships were not modified. The quality of life of patients after laparoscopic surgery for gastroesophageal reflux disease improved and was close to the level expected in a healthy individual.

Laparoscopic ultrasound of the liver.

OBJECTIVE: Despite recent advances in medical imaging, pre-operative evaluation of liver tumors, whether benign or malignant, is often lacking in accuracy and precision. With the development of surgical laparoscopy, the benefits of diagnostic laparoscopy have been combined with those of operative ultrasound. This article aims to describe the technique of laparoscopic ultrasound of the liver, and to define its applications and the role of its association with diagnostic laparoscopy in the localization and assessment for resectability of liver tumors. METHODS: After an initial visual inspection with the laparoscope, laparoscopic ultrasound is utilized to further examine the liver. This relies largely on recognition of branches of the portal vein and tributaries of the hepatic veins. During this procedure, the hepatic parenchyma is also examined. Minimal displacement of the transducer, using clockwise and anti-clockwise rotatory movements, allows a full exploration of the liver. RESULTS: The combination of visual with sonographic laparoscopy allows accurate localization of benign and malignant hepatic tumors, as well as ultrasound-guided biopsies of these. Laparoscopic ultrasound can detect small lesions previously unseen by pre-operative imaging techniques. The relationship of tumors to adjacent blood vessels can be defined. Portal vein thrombosis can be diagnosed. CONCLUSION: Curability and liver tumor resectability can be determined and the appropriate surgical treatment thus planned.

[Comparison of laparoscopic ultrasound and cholangiography during laparoscopic cholecystectomies. Results of a prospective study]. / Comparaison de l'écholaparoscopie et de la cholangiographie lors des cholécystectomies laparoscopiques.

AIM: Prospective evaluation of the results of laparoscopic ultrasound and cholangiography to investigate choledocholithiasis and detect variations in biliary anatomy during laparoscopic cholecystectomies. METHODS: The biliary trees of 600 patients who underwent laparoscopic cholecystectomy were routinely explored by laparoscopic ultrasound and cholangiography. RESULTS: Laparoscopic ultrasound was performed in all 600 cases. Cholangiography was performed in 498 (83%). Laparoscopic ultrasound required less time than cholangiography: 10.2 minutes versus 17.9 minutes (P=0.0001). Common bile duct stones were detected intraoperatively in 40 cases (7%). Both methods were equally effective. The sensitivity of laparoscopic ultrasound was 80% and its specificity 99%. For cholangiography these values were 75% and 98% respectively. For laparoscopic ultrasound, false positives and false negatives were noted in the first 45 cases of individual trainees. Nevertheless, cholangiography showed 30 anatomical anomalies and laparoscopic ultrasound only 15. CONCLUSION: Laparoscopic ultrasound can be performed rapidly and in all cases. Results are comparable to cholangiography in the detection of common duct stones. Individual training is necessary to optimize efficacy. Anatomical anomalies are often missed.

Two-stage laparoscopic management of generalized peritonitis due to perforated sigmoid diverticula: eighteen cases.

The classic treatment of generalized peritonitis due to perforation of sigmoid diverticula is based on the principle of a two-stage surgery with a temporary derivation of the colonic transit. This procedure is associated with a prohibitively high immediate and delayed morbidity, especially associated with the abdominal wound. The laparoscopic approach to this complication is less aggressive and allows a second-stage elective laparoscopic resection. Eighteen consecutive patients (ten women and eight men; average age, 53.7 years) underwent emergency laparoscopic treatment for generalized peritonitis due to perforated diverticula. Eight of these patients had previously had diverticulitis attacks. By peritoneal cavity exploration and full peritoneal lavage (average, 15 L), the infected sigmoid lesion was stuck with biologic glue. A drain was inserted at the site of the lesion and in some cases also in other abdominal zones. No colostomy was necessary. Antibiotic treatment was started at diagnosis and continued for a minimum of 7 days. There was no mortality. Morbidity was limited to three patients (two cases of lymphangitis and one of pulmonary disease). No patient had a wound abscess or residual deep collections. The mean hospitalization was 8 days. Fourteen patients underwent elective laparoscopic sigmoid resection with a delay of 3.5 months. One conversion to laparotomy was necessary. The laparoscopic treatment of generalized peritonitis due to perforated sigmoid diverticula is an interesting alternative to the traditional treatment. It is associated with a lower morbidity, a shorter postoperative hospital stay, and an improvement in the patient's quality of life, because colostomy is avoided. It is also associated with economic savings.

[Is laparoscopic treatment of adhesions a valid approach for postoperative abdominal pain?]. / L'adhesiolyse laparoscopique est-elle licite dans les ventres opérés douloureux?

The role of post-operative adhesions in chronic abdominal pain remains controversial. The aim of this study was to assess the value of laparoscopic treatment of adhesions for chronic post-operative abdominal pain in 32 patients. Over a period of 8 years, 32 patients (25 women and 7 men) with a mean age of 41.5 years (18-69) were hospitalized for chronic abdominal pain of more than 6 months duration, without an obvious underlying neoplasm or psychiatric disorder. They had all undergone at least one previous abdominal operation (mean, 1.9; range, 1-5), with a mean follow-up of 28 months (6-82). The mean duration of the pain was 18 months (6-65) and in 24 of the 32 cases it was mainly hypogastric. Other than the presence of a scar, the clinical examination was completely normal. Prior to hospitalization, 163 different laboratory tests, 162 radiological investigations, including 13 CT scans and 3 MRIs, and 25 endoscopies had been performed. A pneumoperitoneum was made by "open laparoscopy" in 23 cases and with Verres needle in 9 cases. Eight patients (25%) did not have any adhesions, but 6 of them were found to have a gynecological problem (endometriosis). In this group, the laparoscopy lasted 34 minutes (15-45) and the mean hospital stay was 48 hours. In 24 cases, adhesions were found and selected. This was thought to be complete in 22 cases (91.6%). There was a strict correlation between the adhesions and the scar in 85% of cases. In 5 cases, the adhesions were associated with another intervention. There were no conversions. The mean duration of surgery and hospitalization was respectively 56 minutes (32-120) and 3.2 days. There was no mortality and the morbidity rate was 4.1% (1 monopolar injury). The average follow-up was 26.7 months: 22 of the 24 patients who had freeing of adhesions were evaluated after at least 6 months of follow-up. In 10 cases, the pain had completely resolved (45%), in 6 it had decreased (27%) and in 6 cases it was unchanged or had even worsened (1 case of endometriosis). Laparoscopic exploration for chronic post-operative abdominal pain, after an extensive work-up performed after a suitably long delay post-surgery, can be used to detect and treat adhesions in 3/4 cases. In the absence of another lesion, the pain is lessened in 72% cases. However, if there is another lesion, laparoscopic treatment of adhesions is less effective with respect to the pain, but it nevertheless can identify an.

[The effect of the learning curve and the experience on the technique and the outcome of laparoscopic treatment for gastroesophageal reflux]. / Incidence de l'apprentissage et de l'expérience sur la technique et les résultats du traitement laparoscopique de reflux gastro-oesophagien.

The laparoscopic treatment for gastroesophageal reflux disease (GERD) by partial (PF) or total (TF) fundoplication is the current surgical treatment of choice after failure of appropriate medical treatment. The overall results with fundoplication include the initial learning period during which the rate of complications, and failures are assumed to be greater. The aim of this study was to compare the results of laparoscopic treatment for GR in 3 groups of consecutive patients in order to determine the effect of the learning period and the experience on the technique and the outcome. One hundred and fifty patients (84 men and 66 women) with an average age of 52.2 years (18 to 78) were included. Surgery was indicated for failure or early relapse following the end of medical treatment. The preoperative work-up (endoscopy, barium meal or oesophageal pH monitoring) was governed by the clinical picture. The choice between TF and PF was based on the results of pH monitoring. Three groups of 50 patients around were chronologically defined. The parameters that were examined were: the operative technique; the conversion rate; the mortality and morbidity rate; the duration of surgery and hospitalization and the results at short and medium term follow-up. The three groups were comparable with respect to patient characteristics and the nature of their GERD. All patients had an endoscopy, 91% a barium meal, 77.5% underwent esophageal manometry and 67% pH monitoring. One hundred and thirty two patients had a TF and 18 had a PF. Rosetti's type TF became the reference procedure (80.3% in group III) and closure of the diaphragmatic crura was performed systematically in group III (100%). The duration of surgery was significantly reduced between group I and the two other groups (138, 100, 80 mn.). The rate of conversion, due to a variety of causes, decreased from 10.2% to 4% and then 0%. The average duration of hospitalization decreased from 5.8 to 4.2 days (p = 0.01). There was no mortality and the morbidity rate decreased from 14.3% to 4% and then 0%. There was 7 cases of relapse (4.6%), 5 in group 1 (10.2%) and 2 in group II (4%), with no cases in group III although the follow-up is shorter. There is an effect of the learning curve on the outcome of treatment for GR and this must be taken into account in the training of surgeons (training within experienced departments and "guidance" during their initial interventions) and also in publications in order to allow a more accurate comparison of the different treatments for GERD.

[Laparoscopic treatment of acute cholecystitis. Incidence of anatomo-clinical variations (271 cases)]. / Traitement laparoscopique des cholecystites aigues. Incidence des discordances anatomo-cliniques (271 cas).

The study is based on 1050 laparoscopic cholecystectomies for gallstones performed between 1991-1999, out of which 271 were preoperatively considered as acute cholecystitis (25.8%). The clinical, biological and ultrasound criteria were rigorously respected. The preoperative period of 1 to 5 days (mean--2.5) was used for re-equilibration and antibiotic and antithrombotic therapy. The intraoperative criteria were clinical, echolaparoscopical, cholangiographical and bacteriological and established in 219 cases the diagnostic of acute cholecystitis. The final diagnostic, on histopathological basis, confirmed the preoperative diagnosis of acute cholecystitis in 224 cases. The microscopical reexamination in the remainding controversy cases reclassified other 18 as acute cholecystitis (final concordance ratio--242:271). The preoperative overvaluation may be consecutive to a too rapid (before the constitution of specific lesions) or too delayed intervention (the aspect becoming chronical). The elements of diagnostic discordance are raising the problem of case selection and the necessity for standard classification of histological lesions in acute cholecystitis.

Thromboembolism prophylaxis and incidence of thromboembolic complications after laparoscopic surgery.

UNLABELLED: The aim of this prospective study was to assess the clinical thrombo-embolic risk in laparoscopic digestive surgery. METHODS: The study prospectively included 2384 patients, who underwent laparoscopic surgery between June 1992 and June 1997. All patients received peri-operative low molecular weight heparin (LMWH) thromboprophylaxis. This regimen was administered until the patient resumed normal ambulatory activity. RESULTS: Eight cases (0.33%) of deep vein thrombosis (DVT) were observed, but no pulmonary embolism was noted. In 6 cases (5 cholecystectomies with reverse Trendelenburg position and 1 inguinal hernia repair), the pneumoperitoneum was more than 2 h, and in 2 cases (1 rectopexy and 1 sigmoid colectomy for diverticulitis), more than 3 h. In 6 out of the 8 cases, the diagnosis of DVT was established after cessation of LMWH delivery, after the patients were discharged home, and before post-operative day 10. CONCLUSION: During laparoscopic surgery, long operations and reverse Trendelenburg position are potentiating factors to DVT. Heparin prophylaxis for laparoscopic procedures should continue at least until discharge, and continued prophylaxis after discharge should only be considered in individual patients at continued high risk. We also recommend using graduated compression stockings, maintaining a relatively low insufflation pressure, keeping use of the reverse Trendelenburg position to a minimum, and intermittently releasing the pneumoperitoneum in longer procedures.