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.

Migrant adults with diabetes in France: Influence of family migration.

AIM: To explore the influence of migration and this parameters on the control of diabetes. METHODS: A cohort of migrant patients with type 2 diabetes was recruited in a center affiliated to the French national insurance system situated in a department with important migratory phenomenon. Patients fulfilled a questionnaire about diabetes, their migration history, and the EPICES score (deprivation score). We have explored by univariate and multivariate analysis if any of the characteristics of migration could be related to the control of diabetes. This cohort was compared to a non-migrant control group of age and sex-matched patients. RESULTS: We included 72 patients, 36 women and 36 men from 20 different countries. The mean age was 57.7 ± 9.6 years. A migration for family reunification was associated with better diabetes equilibrium (Risk of having an HbA1c ⩾8% (63.9 mmol/mol): OR 0.07 (95% IC [0.005-0.86], p = 0.04). The migrant patients who wished to share their time between France and country of origin during their retirement had a better glycaemic control than the migrant patients who would like to go alone into their country (OR 0.08 [0.01-0.78], p = 0.03). Compared to the non migrant group, the EPICES score was higher in the migrant group (52.8 vs. 28.3, p < 0.05), HbA1c was also higher in the migrant group (8.4 vs. 6.7% (68 vs. 50 mmol/mol)). CONCLUSIONS: We may fear that migrants share an increased risk of uncontrolled diabetes. Individual migration could be a risk factor of uncontrolled diabetes. Knowing the migration history of migrant patients is fundamental to understand some barriers of care.

Rosacea fulminans during pregnancy.

BACKGROUND: Rosacea fulminans (RF) is a severe form of facial dermatosis presenting with a sudden onset of numerous facial pustules, papules, and erythema. During pregnancy its treatment may be difficult and can have an impact on obstetrical outcomes. CASE: A 37-year-old woman during the 37th week of her fourth pregnancy presented RF that was associated with ocular manifestations. The usual treatment with isotretinoin was contraindicated during pregnancy and the patient started an alternative treatment with prednisone and azithromycin. After delivery at 38 weeks of gestational age, there was a significant improvement. CONCLUSION: RE is a severe dermatological disease with unknown etiology and with a rapid improvement in the immediate postpartum period.

Idiopathic spontaneous hemoperitoneum during pregnancy.

Spontaneous hemoperitoneum is defined as bleeding within the peritoneal cavity of non-traumatic and non-iatrogenic etiology. It is a rare and life-threatening condition during pregnancy. Spontaneous hemoperitoneum is considered idiopathic when the source of bleeding is not detected during the exploratory laparotomy. The authors report two cases of spontaneous hemoperitoneum during pregnancy with sudden onset of abdominal pain during the third trimester of their pregnancy. Cesarean section was performed for fetal distress. In both cases, hemoperitoneum with a large quantity of blood was found, but the source of bleeding could not be identified during surgical exploration.

Arterial stiffness is elevated in normotensive type 2 diabetic patients with peripheral neuropathy.

BACKGROUND AND AIMS: Arterial stiffness, a measure of macrovascular damage predictive of poor cardio-vascular outcomes, is strongly related to age and hypertension (HT). In diabetic patients peripheral neuropathy (PN) has been found to be associated with increased arterial stiffness, which might be due to the concomitant presence of HT. The aim of this study was to examine in type-2 diabetic patients, the relationship between arterial stiffness and presence or absence of PN and HT separately. METHODS AND RESULTS: Arterial stiffness was measured with the gold standard carotid-femoral pulse wave velocity (PWV) in 447 type-2 diabetic subjects of whom 66% were hypertensive, 53% had PN, and 40% had both. Patients with PN were older, more often hypertensive and had higher PWV than those free of PN. Patients were separated according to the presence or absence of PN and HT. PWV values above the 90th percentile age- and blood pressure-adjusted reference range (PWV+) were different across these groups (p < 0.005) with the following respective prevalences: 27.2%, 53.4%, 33.3% and 30.6%. Only PWV+ was significantly associated with PN and hypertension in the interaction analysis. CONCLUSION: Well controlled hypertensive patients did not have elevated arterial stiffness compared to normotensive patients. This might be due to anti-hypertensive treatment although our study design does not allow us to confirm it. A strong association between PN and arterial stiffness was only present in normotensive patients, suggesting that normotensive type 2 diabetic patients with PN and elevated arterial stiffness should be carefully managed to prevent future macrovascular complications.

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.

Abdominal pain localization is associated with non-diarrheic Rome III functional gastrointestinal disorders.

BACKGROUND: Abdominal pain is common in patients with functional bowel disorders (FBDs). The aim of this study was to characterize the predominant sites of abdominal pain associated with FBD subtypes, as defined by the Rome III criteria. METHODS: A total of 584 consecutive patients attending FBD consultations in a tertiary center participated in the study. Stool form, abdominal pain location (nine abdominal segments), and pain intensity (10-point Likert scale) during the previous week were recorded. Logistic regression analysis was used to characterize the association of abdominal pain sites with specific FBD subtypes. KEY RESULTS: FBDs were associated with predominant pain sites. Irritable bowel syndrome (IBS) with constipation was associated with pain in the left flank and patients were less likely to report pain in the right hypochondrium. Patients with functional constipation reported pain in the right hypochondrium and were less likely to report pain in the left flank and left iliac site. IBS with alternating constipation and diarrhea was associated with pain in the right flank, and unsubtyped IBS with pain in the hypogastrium Patients with functional abdominal pain syndrome reported the lower right flank as predominant pain site. Patients with unspecified FBDs were least likely to report pain in the hypogastrium. Patients with functional diarrhea, IBS with diarrhea, or functional bloating did not report specific pain sites. CONCLUSIONS & INFERENCES: The results from this study provide the basis for developing new criteria allowing for the identification of homogeneous groups of patients with non-diarrheic FBDs based on characteristic sites of pain.

Insulin- and glucagon-like peptide-1-induced changes in heart rate and vagosympathetic activity: why they matter.

Heart rate (HR) predicts cardiovascular morbidity and mortality in individuals either with or without diabetes. In type 2 diabetic patients, cardiac autonomic neuropathy is a risk marker for cardiac morbidity and mortality. A major pathogenic potential may be attributed to vagal depression and sympathetic predominance. In this issue of Diabetologia, Berkelaar et al (DOI: 10.1007/s00125-013-2848-6 ) examined the effects of euglycaemic, and hyperglycaemic clamp with the addition of glucagon-like-peptide-1 (GLP-1) and arginine, on cardiac vagal control in a large number of healthy subjects. After adjustments for age, BMI and insulin sensitivity, insulin associations with HR remained partially intact while those with vagal control disappeared. This suggested that BMI and insulin sensitivity, but not insulin levels, were the main drivers of cardiac vagal control. GLP-1 infusion during hyperglycaemia increased HR and BP and produced a statistically non-significant decrease in measures of cardiac vagal control compared with values before any manipulation of insulin levels. This commentary summarises how, and to what extent, insulin and GLP-1 affect autonomic nervous system activity, HR and BP. More information is needed on the mechanisms through which acute administration of, and long-term treatment with, GLP-1 may affect haemodynamics and autonomic activity in diabetic and obese patients, since this may influence cardiovascular outcomes.

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.

Screening for deprivation using the EPICES score: a tool for detecting patients at high risk of diabetic complications and poor quality of life.

AIM: Deprivation has been linked to more complicated and uncontrolled diabetes. The validated Évaluation de la précarité et des inégalités de santé dans les centres d'examens de santé (EPICES; Evaluation of the Deprivation and Inequalities of Health in Healthcare Centres) score could help to identify such deprived patients. The present study evaluated the relationships between deprivation and prevalence of complications, uncontrolled diabetes and quality of life. METHODS: This prospective study was conducted in the diabetology department of a tertiary university hospital from November 2006 to July 2007. Patients with diabetes were divided into two groups, according to their deprivation status [non-deprived: EPICES score<30.17; deprived: EPICES score≥30.17 (56.5%)]. Diabetes control, complications and quality of life [Short Form Health Survey (SF-36)] were compared in the two groups. RESULTS: Of a total of 102 patients, 97 completed all of the questionnaires: 18 had type 1 diabetes and 79 had type 2 diabetes, in a geographical area moderately affected by deprivation. No statistical relationship could be demonstrated between deprivation and HbA(1c). Deprived patients with diabetes presented with higher levels of fasting blood glucose, lower levels of LDL cholesterol and a significantly higher risk of obesity (P=0.0020). As for complications, microalbuminuria was linked to deprivation (P=0.03), but no associations with other complications were found. Quality of life was poorer for all physical, mental and social dimensions in deprived patients. CONCLUSION: In this diabetic population, deprivation and glycaemic control were not associated. However, more deprived subjects with diabetes were at higher risk of renal disease. A deprived state was related to an altered quality of life as assessed by the SF-36 score.

Concurrent Graves disease thyrotoxicosis and myasthenia gravis: the treatment of the former may dangerously reveal the latter.

Autoimmune thyroxicosis and myasthenia gravis are often associated. In both diseases, clinical features may include neuromuscular weakness, making their distinction challenging. We report a patient with known Graves disease who presented with generalised fatigue, initially attributed solely to thyrotoxicosis, and who experienced severe respiratory failure linked to associated myasthenia gravis that was unmasked by medication used in the perioperative management of his thyroxicosis. Anaesthetists should always consider myasthenia gravis in cases of hyperthyroidism presenting with neuromuscular features.