Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): impact of the inter-stages course on morbi-mortality and implications for management.

BACKGROUND: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) was recently developed to induce rapid hypertrophy and reduce post-hepatectomy liver failure in patients with insufficient remnant liver volume (RLV). However, mortality rates >12% have been reported. This study aimed to analyze the perioperative course of ALPPS and to identify factors associated with morbi-mortality. METHODS: Between April 2011 and September 2013, 62 patients operated in 9 Franco-Belgian hepatobiliary centres underwent ALPPS for colorectal metastases (N = 50) or primary tumors, following chemotherapy (N = 50) and/or portal vein embolization (PVE; N = 9). RESULTS: Most patients had right (N = 31) or right extended hepatectomy (N = 25) (median RLV/body weight ratio of 0.54% [0.21-0.77%]). RLV increased by 48.6% [-15.3 to 192%] 7.8 ± 4.5 days after stage1, but the hypertrophy decelerated beyond 7 days. Stage2 was cancelled in 3 patients (4.8%) for insufficient hypertrophy, portal vein thrombosis or death and delayed to ≥9 days in 32 (54.2%). Overall, 25 patients (40.3%) had major complication(s) and 8 (12.9%) died. Fourteen patients (22.6%) had post-stage1 complication of whom 5 (35.7%) died after stage2. Factors associated with major morbi-mortality were obesity, post-stage1 biliary fistula or ascites, and infected and/or bilious peritoneal fluid at stage2. The latter was the only predictor of Clavien ≥3 by multivariate analysis (OR: 4.9; 95% CI: 1.227-19.97; p = 0.025). PVE did not impact the morbi-mortality rates but prevented major cytolysis that was associated with poor outcome. CONCLUSIONS: The inter-stages course was crucial in determining ALPPS outcome. The factors of high morbi-mortality rates associated with ALPPS are linked to the technique complexity.

Efficiency of laparoscopic sleeve gastrectomy on metabolic syndrome disorders: two years results.

OBJECTIVES: There are very few studies evaluating the efficacy of sleeve gastrectomy on the metabolic syndrome, truly a worldwide pandemic. The main objective of this study was to retrospectively determine the evolution of the metabolic syndrome and its associated comorbidities (type 2 diabetes, arterial hypertension, and dyslipidemia) at 24 months after sleeve gastrectomy. The secondary objective was to determine the predictive factors for resolution of this syndrome. MATERIAL AND METHODS: Between July 2004 and February 2008, 241 patients with morbid obesity (males: 17%) underwent sleeve gastrectomy in our center. Patients were seen in combined medical and surgical outpatient postoperative follow-up consultation at 3, 6, 12 and 24 months. Patients were classed as responders or not, according to whether or not the metabolic syndrome (as defined according to the National Cholesterol Education Program-Adult Treatment Panel III [NCEP-ATPIII]) disappeared at 24 months follow-up. RESULTS: Thirty-six patients (15% of all patients, 30% of males) presented initially with metabolic syndrome. Twenty-six patients (72%) still had metabolic syndrome at 6 months, 17 patients (47%) at 12 months, and 13 patients (36%) at 24 months. The main parameters that regressed after sleeve gastrectomy were type 2 diabetes and hypertriglyceridemia. In univariate analysis, only one parameter (systolic blood pressure) appeared to be a factor of non-resolution of the metabolic syndrome at 24 months. CONCLUSION: Our study showed that sleeve gastrectomy reduced the incidence of the metabolic syndrome and several of its components.

Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy?

Laparoscopic sleeve gastrectomy (LSG) has a specific morbidity profile in which gastric leak (GL) is the main complication. With a view to defining a standardized protocol for GL management, the present retrospective study sought to describe the clinical patterns of post-LSG GL and treatment of the latter in our university medical center. From July 2004 to December 2010, 25 patients were included. GL was described in terms of clinical presentation, time to onset, and location in the staple line. Treatment of GL with pharmacologic, radiologic, endoscopic, and/or surgical procedures was always validated by a multidisciplinary care team. "Treatment success" was defined as the absence of contrast agent leakage on CT and endoscopy after removal of covered metallic stent or pigtail drains. Systemic inflammation and peritonitis were the main signs for early-onset GL (56%), whereas pulmonary symptoms and intra-abdominal abscesses revealed delayed-onset GL (44%). Surgery was always performed for early-onset GL. In the total study population, the median number of endoscopic procedures was five (range, 1-11) per patient, of covered SEMS was three (range, 1-8), and of pigtail drains was three (range, 1-4). Nine (36%) patients presented endoscopic-related complications. Four (16%) patients with treatment failure underwent radical surgery. The mortality rate was 4% (n = 1). The management of post-LSG GL is challenging. Surgery was always performed for early-onset GL, whereas treatment of delayed-onset GL was based on endoscopy. Pigtail drains required fewer procedures per patient, were better tolerated, and had lower morbidity-mortality than covered SEMS.

Stapling and Section of the Nasogastric Tube during Sleeve Gastrectomy: How to Prevent and Recover?

Bariatric surgery has become an integral part of morbid obesity treatment with well-defined indications. Some complications, specific or not, due to laparoscopic sleeve gastrectomy (LSG) procedure have recently been described. We report a rare complication unpublished to date: a nasogastric section during great gastric curve stapling. A 44-year-old woman suffered of severe obesity (BMI 36.6 kg/m2) with failure of medical treatments for years. According to already published technique, a LSG was performed. Six hours postoperatively, a nurse removed the nasogastric tube according to the local protocol and the nasogastric tube was abnormally short, with staples at its extremity. Surgery was performed with peroperative endoscopy. In conclusion, this is the first publication of a nasogastric section during LSG. Therefore we report this case and propose a solution to prevent its occurrence. To avoid this kind of accident, we now systematically insert the nasogastric tube by mouth through a Guedel cannula. Then, to insert the calibrating bougie, we entirely withdraw the nasogastric tube.