[SOFFCO-MM guidelines for the resumption of bariatric and metabolic surgery during and after the Covid-19 pandemic]. / Recommandations de la SOFFCO-MM en vue de la reprise de l'activité de chirurgie bariatrique et métabolique pendant et après la pandémie Covid-19.

Bariatric/metabolic surgery was paused during the Covid-19 pandemic. The impact of social confinement and the interruption of this surgery on the population with obesity has been underestimated, with weight gain and worsened comorbidities. Some candidates for this surgery are exposed to a high risk of mortality linked to the pandemic. Obesity and diabetes are two major risk factors for severe forms of Covid-19. The only currently effective treatment for obesity is metabolic surgery, which confers prompt, lasting benefits. It is thus necessary to resume such surgery. To ensure that this resumption is both gradual and well-founded, we have devised a priority ranking plan. The flow charts we propose will help centres to identify priority patients according to a benefit/risk assessment. Diabetes holds a central place in the decision tree. Resumption patterns will vary from one centre to another according to human, physical and medical resources, and will need adjustment as the epidemic unfolds. Specific informed consent will be required. Screening of patients with obesity should be considered, based on available knowledge. If Covid-19 is suspected, surgery must be postponed. Emphasis must be placed on infection control measures to protect patients and healthcare professionals. Confinement is strongly advocated for patients for the first month post-operatively. Patient follow-up should preferably be by teleconsultation.

SOFFCO-MM guidelines for the resumption of bariatric and metabolic surgery during and after the Covid-19 pandemic.

Bariatric/metabolic surgery was paused during the Covid-19 pandemic. The impact of social confinement and the interruption of this surgery on the population with obesity has been underestimated, with weight gain and worsened comorbidities. Some candidates for this surgery are exposed to a high risk of mortality linked to the pandemic. Obesity and diabetes are two major risk factors for severe forms of Covid-19. The only currently effective treatment for obesity is metabolic surgery, which confers prompt, lasting benefits. It is thus necessary to resume such surgery. To ensure that this resumption is both gradual and well-founded, we have devised a priority ranking plan. The flow charts we propose will help centres to identify priority patients according to a benefit/risk assessment. Diabetes holds a central place in the decision tree. Resumption patterns will vary from one centre to another according to human, physical and medical resources, and will need adjustment as the epidemic unfolds. Specific informed consent will be required. Screening of patients with obesity should be considered, based on available knowledge. If Covid-19 is suspected, surgery must be postponed. Emphasis must be placed on infection control measures to protect patients and healthcare professionals. Confinement is strongly advocated for patients for the first month post-operatively. Patient follow-up should preferably be by teleconsultation.

A French National Study on Gastropleural and Gastrobronchial Fistulas After Bariatric Surgery: the Impact of Therapeutic Strategy on Healing.

PURPOSE: Gastropleural and gastrobronchial fistulas (GPF/GBFs) are serious but rare complications after bariatric surgery whose management is not consensual. The aim was to establish a cohort and evaluate different clinical presentations and therapeutic options. MATERIALS AND METHODS: A multicenter and retrospective study analyzing GPF/GBFs after bariatric surgery in France between 2007 and 2018, via a questionnaire sent to digestive and thoracic surgery departments. RESULTS: The study included 24 patients from 9 surgical departments after initial bariatric surgery (21 sleeve gastrectomies; 3 gastric bypass) for morbid obesity (mean BMI = 42 ± 8 kg/m2). The GPF/GBFs occurred, on average, 124 days after bariatric surgery, complicating an initial post-operative gastric fistula (POGF) in 66% of cases. Endoscopic digestive treatment was performed in 79% of cases (n = 19) associated in 25% of cases (n = 6) with thoracic endoscopy. Surgical treatment was performed in 83% of cases (n = 20): thoracic surgery (n = 5), digestive surgery (n = 8), and combined surgery (n = 7). No patient died. Overall morbidity was 42%. The overall success rate of the initial and secondary strategies was 58.5% and 90%, respectively. The average healing time was approximately 7 months. Patients who had undergone thoracic surgery (n = 12) had more initial management failures (n = 9/12) than patients who had not (n = 3/12), p = 0.001. CONCLUSION: Complex and life-threatening fistulas that are revealed late require a multidisciplinary strategy. Thoracic surgery should be reserved once the abdominal leak heals; otherwise, it is associated with a higher risk of failure.

C-Reactive protein and procalcitonin for the early detection of postoperative complications after sleeve gastrectomy: preliminary study in 97 patients.

BACKGROUND: Fistula is the most fearsome complication after sleeve gastrectomy. The outcome depends on early and timely diagnosis. C-reactive protein (CRP) and procalcitonin (PCT) have not been extensively evaluated in this context. OBJECTIVE: This study aimed to evaluate the interest of C-reactive protein (CRP) and procalcitonin (PCT) assay for the early detection of gastric fistula after sleeve gastrectomy and to study the PCT as an adjunctive marker to the CRP. SETTING: Private Practice. PATIENTS AND METHODS: This is a retrospective analysis of data collected prospectively. This study was carried out in 97 patients who underwent sleeve gastrectomy between January 2011 and December 2012. The fistula is an abnormal connection between two organs. An abscess is a collection of pus. RESULTS: The rate of postoperative complications (fistulas and abscesses) was 7.2 %. The incidence of fistula was 2 % and the incidence of abscess was 5 %. Both CRP and PCT were significantly higher in patients with postoperative fistula or abscess. Mean CRP was 61.3 mg/l in patients without complications and 161.3 mg/l in case of complications (p = 0.02). Mean postoperative PCT was 0.062 ng/ml in uncomplicated patients versus 0.108 mg/l in those with complications (p = 0.0006). CRP and PCT measured during the postoperative period were correlated with the occurrence of postoperative complications. CONCLUSION: Early detection of fistula or abscess after sleeve gastrectomy simplifies the management of these complications. While the ideal biomarker of infection does not yet exist, this study shows that clinical observations in association with CRP and PCT measurements could be of help for the early detection of septic complications after sleeve gastrectomy.

Biomechanics of A-to-T flap design.

OBJECTIVES/HYPOTHESIS: The objective of this study was to determine the vertical height, horizontal incision width, and extent of undermining that correlated with the lowest closure tension. STUDY DESIGN: Prospective, cadaver study. METHODS: Forty "A-to-T" flaps were made on the torso and lower extremities of fresh cadavers. Ten flaps each were designed at heights of three, four, and five defect radii. Closing tensions were measured for each of these flaps initially, followed by serial base extensions. Based on the information from these first flaps, 10 additional flaps were made at the optimal height and base extensions. These flaps were then serially undermined and tension measurements taken. RESULTS: Our results suggest that making the vertical height of the "A" twice the height of the defect yields a significant decrease in tension of closure when compared with a vertical height one and a half times the defect (P < .01), while increasing the height to two and a half times the defect height provides only a minimal further reduction in closure tension. Extending the base (horizontal) incision one defect diameter in each direction offers the greatest reduction in closing tension. Undermining up to three times the diameter of the defect offers progressive improvement in the tension of closure, while further undermining confers little additional benefit. CONCLUSIONS: Our findings indicate that the ideal A-to-T flap is designed to be twice the height of the original defect, with base extensions one defect diameter in each direction, and undermined to three times the diameter of the defect.

Management of malar folds in blepharoplasty.

OBJECTIVES/HYPOTHESIS: To define the anatomy and location of malar folds as distinguished from lower eyelid skin and orbital fat and to teach a new surgical technique for the management of the aging eye. STUDY DESIGN: Retrospective report of a surgical procedure designed to address the malar folds. METHODS: Analysis of preoperative and postoperative photographic documentation for surgical planning and long-term result. RESULTS: Patient satisfaction and lack of recurrence, without the requirement of direct excision, were noted in all patients studied. CONCLUSION: This presentation describes a new simple technique for the management of the folds and cutaneous and subcutaneous prominences that occur inferior to the lower eyelid skin. The operation addresses the correction by a combination of skin/muscle flap lower eyelid blepharoplasty with immediately subcutaneous (skin flap) elevations over the carefully delineated malar prominences; the removal of the deep fat that may or may not be associated with dehiscence of fat through the thin inferior fibers of the orbicularis muscle; and finally suspension of the remaining subcutaneous tissue and the muscle to the periosteum of the inferior orbital rim as well as suspension of the orbicularis muscle margin to the lateral orbital periosteum or the lateral canthal ligament area. The technique is designed to manage the more commonly found malar prominences but can be applied in the management of more pronounced festoons involving skin, muscle, and fat.

Osteosarcoma of the head and neck: meta-analysis of nonrandomized studies.

To assess the role of adjuvant therapy in the treatment of osteogenic sarcoma of the head and neck, treatment and survival information from 173 patients with osteosarcoma of the head and neck was entered into a database. A meta-analysis of the data was attempted with primary emphasis on the effect of adjuvant therapy on disease outcome. The overall 5-year survival was 37%. Patients with mandibular and maxillary tumors had similar survival rates; both groups fared significantly better than patients with extragnathic tumors (P<0.001). Treatment with surgery alone was associated with significantly longer survival rates (P<0.03) than surgery with adjuvant therapy. In the majority of patients reported, information about surgical margins was not available. For this reason, the differences may not adequately represent the effect of adjuvant therapy. While there have been encouraging results with adjuvant treatment protocols for long bone osteosarcoma, the ultimate role of radiation and chemotherapy in the management of osteosarcoma of the head and neck remains unproven. Nevertheless, we recommend that adjuvant therapy be considered due to the poor prognosis in osteosarcoma of the head and neck.

Biomechanics of the helical rim advancement flap.

OBJECTIVES: To determine how helical rim closure with advancement flaps affects ear length and cupping, to compare the tension of closure with wedge excision and helical rim advancement and the effects of 3 tension-decreasing surgical techniques, and to review clinical experience with this flap. DESIGN: The laboratory study was performed on 6 fresh cadaver ears, by means of sequential excision of tissue, and closure tension was measured with a strain gauge. Results obtained in 10 patients were reviewed. SETTING: University referral hospital. PATIENTS: Ten patients with helical rim defects treated with helical rim advancement flaps. INTERVENTION: In cadaver ears, a helical rim defect of 5 mm was enlarged sequentially to 10 mm, 15 mm, and finally 20 mm. In the patients, defects of the helical rim caused by trauma or tumor were closed by this helical rim advancement flap method. MAIN OUTCOME MEASURES: For the laboratory study, the outcome measures were tension of closure of the defect, ear length, and ear cupping. For the review of cases, outcome was determination of perioperative complications and the patient's and surgeon's judgment of cosmetic appearance. RESULTS: Closure of a helical rim defect with advancement flaps caused minor shortening and moderate cupping of the ear. The tension of closure was decreased by extending the inferior incision into the earlobe, creating a Burow triangle, and shaving cartilage from the scapha. Both the Burow triangle and the scaphal shave caused mild increases in ear cupping. CONCLUSION: Helical rim advancement flaps provide satisfactory closure of helical rim defects up to at least 20 mm (longer in some ears) with excellent preservation of normal anatomic landmarks and a near-normal appearance of the reconstructed ear.

In situ studies of the primary immune response to (4-hydroxy-3-nitrophenyl)acetyl. I. The architecture and dynamics of responding cell populations.

After primary immunization with an immunogenic conjugate of (4-hydroxy-3-nitrophenyl)acetyl, two anatomically and phenotypically distinct populations of antibody-forming cells arise in the spleen. As early as 2 d after immunization, foci of antigen-binding B cells are observed along the periphery of the periarteriolar lymphoid sheaths. These foci expand, occupying as much as 1% of the splenic volume by day 8 of the response. Later, foci grow smaller and are virtually absent from the spleen by day 14. A second responding population, germinal center B cells, appear on day 8-10 and persist at least until day 16 post-immunization. Individual foci and germinal centers represent discrete pauciclonal populations that apparently undergo somatic evolution in the course of the primary response. We suggest that foci may represent regions of predominantly interclonal competition for antigen among unmutated B cells, while germinal centers are sites of intraclonal clonal competition between mutated sister lymphocytes.