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.

Drug exposure and perceived adverse drug events reported by liver-transplant patients.

INTRODUCTION: Posttransplant patient outcome and quality of life are affected by different factors, such as post-graft context, psychological state, and polymedication. Many surveys have been carried out to study immunosuppressant ADRs, and have mainly used a questionnaire completed by patients, but few have asked patients about their drug exposure. The aim of this study is to describe drug exposure and adverse drug events (ADEs) reported by liver-transplant patients (LTP). METHODS: This observational, retrospective study assessed questionnaires from LTPs concerning demographic data, drug exposure, and ADEs. RESULTS: 118 LTPs exposed to 5.9 (+/- 2.8) drugs with immunosuppressive regimens, consisting mainly of tacrolimus (79.3%), cyclosporine (18.1%), or sirolimus (2.6%), were also exposed to antihypertensive drugs (43.2%), protonpump inhibitors (30.5%), statins (28.8%), drugs acting on bile composition (26.3%), and diuretics (19.5%). 1,389 ADEs were reported: 30.1% neurological, 13.4% cutaneous, 12.4% hematological, 11.1% digestive, 10.1% osteomuscular, 6.6% cardiovascular, and 16.3% others. Significantly more ADEs were reported by patients exposed to cyclosporine than those receiving tacrolimus (p < 0.05). Patients with a transplant for < 18 months had more tremors and those with a transplant for > 79 months reported more hirsutism, gingival hypertrophia, and arterial hypertension. CONCLUSIONS: This study shows the value of patient-reporting via structured interviews for both drug exposure and ADEs, and the importance of this approach to complement total data collection.

Biological changes after liver transplantation according to the presence or not of graft steatosis.

AIM: To assess the consequences of graft steatosis on postoperative liver function as compared with normal liver grafts. PATIENTS AND METHODS: From January 2005 to December 2007, liver transplant patients were prospectively included, excluding those who experienced arterial or biliary complications or presented acute rejection. All patients had a surgical biopsy after reperfusion. Patients were compared according to the rate of macrovacuolar steatosis: namely above or below 20%. RESULTS: Fifty-three patients were included: 10 in the steatosis group and 43 in the control group. No significant difference was observed in terms of morbidity, mortality, and primary non- or poor function. Nevertheless, biological changes after the procedure were significantly different during the first postoperative week. Prothrombin time, serum bilirubin, and transaminases were significantly increased among the steatosis group compared with the control group (P < .05). CONCLUSION: This case-controlled study including a small number of patients, described postoperative biological changes among liver transplantations with steatosis in the graft.

Orthotopic liver transplantation with vena cava preservation in cirrhotic patients: is systematic temporary portacaval anastomosis a justified procedure?

INTRODUCTION: We evaluated the peri- and postoperative effects of the lack of a temporary portocaval anastomosis (TPCA) during orthotopic liver transplantation (OLT) in 84 patients with cirrhosis. PATIENTS AND METHODS: From December 1996 to December 2002, 156 liver transplant recipients included (54%; 60 men and 24 women) of mean age 52 +/- 9 years with portal hypertension. In whom peri- and postoperative data were analyzed. RESULTS: The median fall in mean arterial pressure upon vascular clamping and unclampings was 20 mm Hg (range 15 to 75), while the median duration of portal vein clamping was 77 minutes. The median amount of blood autotransfusion was 1100 mL (range 0 to 5400). The median number of red blood cell and fresh-frozen plasma units transfused were 5 and 6.5, respectively. The median intraoperative urinary output was 72 mL/h (range 11 to 221). Three patients (3.5%) presented a perioperative complication, but no perioperative death was observed. Six patients experienced an early postoperative complication (<10 days): five hemodynamic complications and one transient renal failure, which did not require hemodialysis. One patient (1%) died at 12 hours after OLT from acute pulmonary edema. CONCLUSION: This study shows that systematic TPCA during OLT with preservation of the native retrohepatic vena cava in cirrhotic patients does not appear to be justified. In contrast, peri- and postoperative hemodynamic parameters as well as blood component requirements were comparable to those of the literature reporting OLT with straightforward TPCA.

[Recurrent pancreatitis after pancreaticoduodenectomy: reoperation for stenosis of the pancreaticojejunostomy]. / Pancréatites récidivantes après duodénopancréatectomie céphalique: réintervention pour sténose de l'anastomose pancréatico-jéjunale.

Stenosis of the pancreaticojejunostomy is a late and rarely symptomatic complication of pancreaticoduodenectomy, observed in approximately 30% of cases. Treatment of symptomatic strictures is difficult. We report a case of reoperation for stenosis of the pancreaticojejunostomy responsible for recurrent pancreatitis. The treatment strategy is discussed.

[Hiatus calibration decreases postoperative dysphagia after laparoscopic fundoplication: case-report study]. / Le calibrage de l'orifice hiatal diminue la dysphagie postopératoire après la cure de reflux gastro-oesophagien par laparoscopie: étude cas-témoins.

STUDY AIM: The risk of dysphagia after antireflux surgery seems to be increased with laparoscopy compared with open surgery. Calibration of the hiatus is usually done by the surgeon's finger during open surgery. The aim of this study was to assess the results of laparoscopic calibration with a Fogarty balloon catheter. PATIENTS AND METHODS: Between 1999 and 2001, 21 patients had a laparoscopic Toupet 240 degrees fundoplication with hiatus calibration using a 4 ml-inflated 8G Fogarty balloon catheter. These patients were compared with a group of 21 patients without hiatus calibration, matched for age, sex, preoperative dysphagia and esophageal dysmotility. Judgment criteria was early and/or late postoperative dysphagia (> 3 months). RESULTS: Median follow-up was 13 months. The rate of early dysphagia with and without calibration were 66% and 48% respectively (NS). Median duration of early dysphagia with and without calibration were 25 and 43 days respectively (p = 0.05). No patient with calibration had late dysphagia. One patient (5%) without calibration had unexplained late dysphagia for 2 years. He had preoperative esophageal dysmotility without oesophagitis. CONCLUSION: Hiatus calibration with a Fogarty balloon catheter decreased early postoperative dysphagia duration after Toupet laparoscopic fundoplication. This easily reproducible technical point standardizes the hiatus closure and should be recommended.

[Reoperation for refractory postoperative chylous ascites: value of peritoneovenous shunt combined with closure of lympho-peritoneal fistula]. / Réintervention pour ascite chyleuse postopératoire réfractaire: intérêt du shunt péritonéojugulaire associé à la ligature des lymphatiques.

Postoperative chylous ascites is a rare but serious complication resulting in denutrition, lymphopenia and infection. The first-intent treatment is usually conservative. We report a case of chylous ascites after retroperitoneal lymphadenectomy for testicular cancer, persisting despite conservative treatment then successfully treated by lymphostasis combined with peritoneovenous shunt. In case of high-output postoperative chylous ascites in low-risk patients with presumed localization of fistula, reoperation is indicated for lymphostasis. We advise to associate a peritoneovenous shunt in case of incomplete closure of the lymphoperitoneal fistula to avoid the morbidity of prolonged ascites.

Ethical, legal and economic issues raised by the use of human tissue in postgenomic research.

Ethical, legal and economic framework issues concerning human samples, genetic data and bioresources are rapidly evolving. In most cases, international standards have not been defined. National legislations on the use and exploitation of human sample collections differ widely. Legislations relating to intellectual property rights, access to database information for public or private bodies, of national or foreign origin, are similarly diverse. Importation and exportation rules, concerning in particular data protection, biosafety and protection of individual rights, have not always been defined. This article makes a short assessment of the legal, ethical and economic framework in selected EC countries (Germany, France and UK), and compares them with the conditions in the USA. On the basis of the information collected, it is obvious that the use of human cells, tissues and organs in medical research has to be considered as a global, worldwide question. Such use has profound ethical, cultural and economic consequences not only in the country of origin, but also globally. Biotechnology and pharmaceutical companies conducting research with human samples are facing different framework conditions in the area of data protection, policy measures, economic support, exportation, etc., that already influence trade activities and investments of such firms at the international level. Over the 3 last years, a trend towards harmonization can be recognized: the World Health Organization has recognized the problems of postgenomic medical research as a priority. The OECD has created a taskforce on centers for biological resources. Biobanks are a common theme of the French and the German National Ethic Councils. A lack of international harmonization and consistency might not only present a challenge to biotechnology and pharmaceutical companies, but can also endanger the goals the laws and regulations seek to achieve.

[Cystic pancreatic tumors]. / Les tumeurs kystiques du pancréas.

Cystic tumors of the Pancreas (CTP) are rare (less than 5% of all pancreatic tumors). We have limited our study to CTP of epithelial origin which represent 90% of all CTP. These can be divided into three subgroups: (1) Benign tumors with no risk of malignant progression (serous cystadenoma). (2) Tumors with risk of malignant degeneration (mucinous cystadenoma, intraductal papillary mucinous tumors (IPMT), and pancreatic solid-cystic papillary tumor. (3) Malignant tumors (cystadenocarcinoma, IPMT with malignant degeneration). The latter two groups of CTP require radical resection while serous cystadenoma does not require surgical intervention unless symptomatic. The ability to determine preoperatively the exact nature of a CTP is of tremendous importance; cytologic examination and biochemical assays of cyst fluid aid greatly in this determination. Better understanding of the biologic evolution of CTP has increased the indications for surgical resection but the risks of postoperative morbidity and mortality in these patients must not be underestimated.

[Large abdominal parietectomy for late abdominal wall recurrence of colonic cancer: reconstruction with latissimus dorsi free flap with delayed insertion]. / Pariétectomie abdominale étendue pour récidive pariétale tardive d'un cancer colique: reconstruction par un lambeau libre de muscle grand dorsal à insertion différée.

Parietal recurrence following conventional treatment of colorectal cancer is an infrequent event and is usually associated with an intra-abdominal recurrence. The study aim was to report a large solitary abdominal wall recurrence observed 80 months after the resection of a sigmoid adenocarcinoma and treated by a left hemiparietectomy associated with a segmental colectomy. The abdominal wall reconstruction combined a prosthesis and a latissimus dorsi myocutaneous free flap with delayed insertion after initial transfer.

[Radio-guided resection of residual metastatic lymph node from a previously resected neuroendocrine tumor]. / Exérèse radioguidée d'une adénopathie résiduelle métastatique d'une tumeur neuroendocrine antérieurement réséquée.

Neuroendocrine tumors are slowly growing and carry a high risk of recurrence. Somatostatin receptor scintigraphy is considered as the gold standard for preoperative evaluation and postoperative follow-up. The use of an intraoperative detection probe makes easier a complete resection of abdominal residual or recurrent tumor. These resections may be incomplete because of the small size of the tumor and the postoperative adhesions. Radio-guided surgery is recommended in order to reduce the need for reoperation.

[Experimental study of monopolar electrical and ultrasonic dissection]. / Etude expérimentale comparant bistouri électrique monopolaire et bistouri ultrasonique.

The aim of this experimental study was to compare the disadvantages of a monopolar electric scalpel and an ultrasonically-activated scalpel in a porcine model. Using thermal gradients, the ultrasonically-activated scalpel significantly decreased thermal energy dispersion to surrounding structures and thus decreased the risk of injuries to adjacent tissues and nerves, as opposed to the monopolar electric scalpel. Histological examination of nerves showed that necrosis was significantly less important with the use of the ultrasonically-activated scalpel. This experimental study demonstrated that the ultrasonically-activated scalpel caused less thermal and histological damage than the monopolar electric scalpel.

[Liver transplantation in the presence of a non-functional portal vein: an original technique]. / Transplantation hépatique en présence d'une veine porte non fonctionnelle: une technique originale.

STUDY AIM: The aim of this retrospective study was to report an original technique for heterotopic liver transplantation with the graft in the left hypochondrium, and to discuss the indications and limitations of this technique. PATIENTS AND METHOD: Over the past ten years, four patients were treated by this technique; this constitutes 2% of all liver transplantations carried out during this period. RESULTS: No immediate per- or postoperative mortality related to the surgical procedure was noted. Moreover, no severe hemodynamic complications occurred during the per- or postoperative period. In three out of four cases, hepatic function was fully restored within 48 hours. Long-term survival (50 and 97 months) was observed in two patients. CONCLUSION: Heterotopic liver transplantation in the left hypochondrium is an alternative to orthotopic liver transplantation; it is a technique that is easy, non-aggressive, and with good long-term results. It is indicated in cases where the main portal vein is non-functional (following total thrombosis or porto-caval shunt), and orthotopic liver transplantation is therefore not possible.

Adjuvant intraperitoneal 5-fluorouracil in high-risk colon cancer: A multicenter phase III trial.

OBJECTIVE: To evaluate the results of a prospective multicenter randomized study of adjuvant intraperitoneal 5-fluorouracil (5-FU) administered during 6 days shortly after resection of stages II and III colon cancers. SUMMARY BACKGROUND DATA: Systemic adjuvant chemotherapy improves the survival of patients with stage III colon cancer receiving treatment for 6 months. Intraperitoneal chemotherapy theoretically combines peritoneal and hepatic effects. METHODS: After resection, 267 patients were randomized into two groups. Patients in group 1 (n = 133) underwent resection followed by intraperitoneal administration of 5-FU (0.6 g/m2/day) for 6 days (day 4 to day 10). These patients also received intravenous 5-FU (1 g) during surgery. Patients in group 2 underwent resection alone (n = 134). RESULTS: In group 1, 103 patients received the total dose, 18 received a partial dose as a result of technical or tolerance problems, and 12 did not receive the chemotherapy. Rates of surgical death and complications were similar in both groups. Tolerance to treatment was excellent or fair in 97% of the patients and poor in 3%. After a median follow-up of 58 months, 5-year overall survival rates were 74% in group 1 and 69% in group 2; disease-free survival rates were 68% and 62%, respectively. Survival curves were superimposed until 3 years after treatment and began diverging thereafter. Among patients receiving the full treatment, the 5-year disease-free survival rate was improved in the treatment group in patients with stage II cancers but was unchanged in patients with stage III cancers. CONCLUSIONS: Chemotherapy with intraperitoneal 5-FU administered during a short period after surgery was well tolerated but was not sufficient to reduce the risk of death significantly. However, it reduced the risk of recurrence in stage II cancers. These results suggest that it should be associated with systemic chemotherapy to reduce both local and distant recurrences.

[Surgery for pathological obesity]. / Chirurgie de l'obésité morbide.

Morbid obesity is defined by a body mass index greater than 40 kg/m2 and constitutes a real disease, which shortens the patient's life expectancy, especially as a result of multiple metabolic, endocrine or respiratory complications. Since it has been demonstrated that these complications are improved by weight loss and as diets very often fail, surgical treatment has been proposed to these patients. Techniques have advanced since the 1960s: intestinal bypasses have been abandoned because of complications related to malabsorption. Biliopancreatic or gastric bypasses may be proposed to extremely obese patients, but most patients can benefit from vertical or inflatable ring gastroplasty, which is adjustable and reversible. It can be performed by laparoscopy which limits postoperative complications and the incisional hernias classically observed after laparotomy. This treatment can only be considered in the context of a multidisciplinary team composed of an endocrinologist, psychologist and dietician to ensure good selection and attentive follow-up of patients.