Weight loss and quality of life after bariatric surgery: a study of 200 patients after vertical gastroplasty or adjustable gastric banding.

BACKGROUND AND OBJECTIVES: Long term evaluation of bariatric surgery must include quality of life measurement. METHODS: Quality of life (QoL) was evaluated using the original Moorehead-Ardelt questionnaire for 200 patients operated for massive obesity in a single centre between 1994 and 2003. QoL and physical data were obtained by retrospective mail questionnaire. Surgical procedures were vertical-banded gastroplasty according to Mason (VBGM) and adjustable gastric banding (AGB) in 61 and 39% of patients, respectively. The aim of the study was to assess the nutritional outcome and QoL according to the procedure. RESULTS: Overall, the body mass index (BMI) decreased from 50+/-8 kg/m(2) before surgery to 35.2+/-7.5 kg/m(2) at the time of the questionnaire. The percentage of weight loss was 28.8+/-12.2%. In the group treated with VBGM, the mean initial weight (P=0.003) and the percentage of weight loss (P<0.001) were significantly higher, and the QoL was better (P=0.003) than in the group treated with AGB. On the basis of the time spent since surgery, a regular weight loss was observed during the first 5 years, whereas weight subsequently increased over the five following years. Similarly, the total QoL score gradually improved during the first 5 years and worsened thereafter. However, it remained better than before surgery. A linear regression analysis showed a positive correlation between the percentage of weight loss and the QoL score (P<0.001). CONCLUSIONS: This study suggests that the bariatric surgery, particularly the VBGM technique, improved the QoL of obese patients, at least in the first 5 years following surgery.

Evaluation of selective defunctioning stoma after low anterior resection for rectal cancer.

BACKGROUND: Anastomotic leakage is a major concern after resection for low rectal cancer. Therefore, the use of a defunctioning stoma (DS) has been suggested, but limited data exist to clearly determine the necessity of a routine diversion. In our department, the indication of DS was evaluated subjectively by the operating surgeon. The aim of this study was to evaluate the selective use of fecal diversion. MATERIALS AND METHODS: Retrospective chart review of patients who underwent low anterior resection for carcinoma was performed. The incidence and consequences of clinical leaks were determined in these patients who were considered in two groups: defunctioning stoma and no defunctioning stoma. RESULTS: From 1995 to 2005, 132 consecutive patients underwent low anterior resection; a DS was performed in 42 patients (31.8%). Median level of anastomosis was 4 cm in both groups. Overall clinical leakage rate was 9.8%: 7.1% (n = 3) with a DS and 11% (n = 10) without a stoma. Mortality rate was 1.5% (n = 2), both in the unprotected group. No patient in the diversion group required a permanent stoma, contrasting with four unprotected patients in which continuity could not be restored after break down of the anastomosis. CONCLUSION: Finding lower clinical leakage rate in a probable higher risk group and better outcome when a leak occurs in our study constituted strong evidence of the effectiveness of a DS. Selective use of a DS based on subjective assessment at the time of surgery could not allow experienced surgeons to perform single-stage procedure safely. Construction of a DS seems useful for patients with distal rectal cancer.

Treatment of anovaginal or rectovaginal fistulas with modified Martius graft.

OBJECTIVE: The treatment of ano- or rectovaginal fistula is still difficult. The use of the Martius flap is well described as an adjunctive technique in their repair. We report our experience of a modified Martius flap in the management of ano- or rectovaginal fistula. METHOD: This is a retrospective study of 14 women presenting with an anovaginal (n = 9) or rectovaginal fistula (n = 5). All were treated by a modified Martius graft. The aetiology included Crohn's disease (n = 7), ulcerative colitis (n = 4), radio-induced (n = 1), obstetric (n = 1) and villous tumour (n = 1). RESULTS: All 14 fistulas healed within the 3 months after surgery. Subsequently, two patients with Crohn's disease required an abdominoperineal resection owing to progressive anal lesions. Two other patients experienced faecal incontinence which improved with functional rehabilitation treatment. CONCLUSION: A modified Martius flap is a valuable option in the treatment of ano- or rectovaginal fistula. In the case of Crohn's disease, however, the prognosis depends primarily on subsequent clinical evolution of the condition.

[Laparoscopic ovarian transposition and cryopreservation of ovarian tissue before chemo-radiotherapy for rectal cancer]. / Transposition ovarienne par coelioscopie et cryopréservation de tissu ovarien avant radiochimiothérapie d'un cancer du rectum.

We report a case of laparoscopic ovarian transposition and ovarian cryopreservation in a nulliparous 25-year-old woman with rectal cancer. The authors focus on the surgical technique and the importance of preserving ovarian function.

[Management of pregnancies after adjustable gastric banding]. / Prise en charge des grossesses après anneau gastrique ajustable.

OBJECTIVES: To report our experience of the association adjustable gastric banding and pregnancy. To define a management for a such association. MATERIALS AND METHODS: Retrospective and descriptive study on two centers over a 3-year follow-up of pregnancies begun with a Lap-Band gastric banding placed by laparoscopic way. RESULTS: Twenty-one pregnancies, 22 newborns resulting from 18 women were identified. Eleven patients were hospitalized. The motive of the hospitalization was severe epigastralgia for four patients requiring three deflations for mechanical complication. No case of preeclampsia was identified. Seven bands were deflated. In the group of the deflated bands, the mean maternal weight gain was 19 vs 10 kg (P=0.008), the mean birth weight was 3700 vs 3204 g (P=0.09) with a rate of fetal macrosomia increased, 50 vs 29% (P=0.038). The difference between the rates of cesarean delivery was not significant (NS) between the two groups. The childbirth term was appreciably the same, 39.4 vs 38.6 weeks of gestation (NS). The only case of gestational diabetes was found in the deflated band group. Three intrauterine growth restrictions whose one fetal death occurred in the not deflated band group. CONCLUSION: Results obtained were comparable to those of the literature. This series confirms that adjustable gastric banding limits the usual complications of the morbid obesity during pregnancy. It is generally well tolerated and must not be thus deflated by principle, but only on symptoms. That will be a total dysphagia, severe epigastric pains, vomiting after the first trimester of pregnancy or an intrauterine growth restriction.

[Treatment of colovesical fistula: predictive factors of the maintenance of long-term digestion continuity]. / Traitement des fistules colovésicales: facteurs prédictifs du maintien de la continuité digestive à long terme.

AIM OF THE STUDY: Colovesical fistulas (CVF) may occur in inflammatory or tumoral pelvic diseases. The aim of this study was to analyze the surgical management of patients with a CVF in order to define predictive factors of good results and long term digestive continuity. PATIENTS AND METHODS: From 1989 to 1999, this retrospective study included 37 patients, 19 men and 18 women, mean age: 69 years (range 37-93 years). Main etiologies were colonic diverticulitis (n = 22) in 60% of the patients, cancer (n = 6) in 16%, previous radiotherapy (n = 5) in 14%. Treatment was a diverting colostomy in 13 cases, a colectomy in 24 cases without diverting colostomy in 10 cases. RESULTS: Overall postoperative mortality rate was 16%. With a mean follow-up of 47 months, digestive continuity was restored in 40% of the patients (100% in ASA 1 patients, 55% in ASA 2, 19% in ASA 3 and 0% in ASA 4). CONCLUSIONS: Our study suggests that long term digestive continuity following surgical treatment of colovesical fistulas does not depend upon etiology or surgical treatment but mainly upon the patient's ASA score.

Up-regulated expression of HGF in rat liver cells after experimental endotoxemia: a potential pathway for enhancement of liver regeneration.

A lipopolysaccharide (LPS)-induced inflammation prior to an hepatic resection has been shown to enhance liver regeneration in rat. The aim of the present study was to investigate the expression of hepatocyte growth factor (HGF) and its c-Met receptor under such experimental conditions. Animals were submitted to a two-third hepatectomy or a LPS challenge carried out 12 h prior to resection. Non parenchymal and parenchymal cells were isolated from livers obtained at various times post-hepatectomy. Quantitative RT-PCR for HGF and c-Met mRNAs were performed from total liver or purified cell fractions and HGF mRNA was also analyzed by in situ RT-PCR on liver sections. A LPS challenge alone induced a marked up-regulation of HGF mRNA level in whole liver and isolated hepatocytes. Furthermore, when partial hepatectomy (PH) was preceded by a LPS challenge, an increase of HGF mRNA level was seen in whole liver and contrasted with a decreased level in non parenchymal cells. These results were confirmed by in situ RT-PCR. In isolated hepatocytes from endotoxemic rats, the mRNA level for the LPS-specific membranous receptor mCD14 was markedly up-regulated and even more so when LPS was followed by PH. Moreover, a TNFalpha challenge alone induced an up-regulation of HGF mRNA in hepatocytes and a down-regulation in non parenchymal cells (NPCs). Overall, when a LPS challenge is given prior to PH the major source of hepatic HGF appears to be the hepatocyte itself rather than NPCs. An autocrine HGF/c-Met loop which promotes the proliferative potential of the hepatic parenchymal cell and participates in liver regeneration is postulated.

[Role of complementary tests in the management of colo-vesical fistulae]. / La place des examens complémentaires dans la prise en charge des fistules colo-vésicales.

OBJECTIVE: Colo-vesical fistulas (CVF) are a complication of inflammatory or neoplastic diseases of the lesser pelvis. Although the clinical diagnosis is obvious in the presence of pneumaturia or faecaluria, a number of patients require complementary diagnostic and/or pretreatment investigations. The objective of this study was to analyse the management of these patients in order to define the place and cost-effectiveness of complementary investigations. MATERIAL AND METHODS: This retrospective study was based on 37 patients with a colo-vesical fistula, secondary to sigmoid diverticulitis in 60% of cases. RESULTS: Cystoscopy was the most cost-effective examination for the diagnosis of CVF with a sensitivity of 94%. The preoperative assessment of CVF and the underlying disease was optimally performed by a combination of cystoscopy, opaque enema and CT. CONCLUSIONS: Our study defined the place of the various examinations in the assessment of colo-vesical fistula, but the value of magnetic resonance imaging, not performed in this series, remains to be defined.

Distal gastrectomy and Roux-Y limb in the rat: plasma motilin, pancreatic polypeptide concentrations, and duodenojejunal motility.

After gastrectomy, Roux-Y limb reconstruction leads to duodenojejunal motor disturbances. Because motilin and pancreatic polypeptide (PP) play a role in the regulation of digestive motility, their plasma concentrations were determined in rats after Roux-Y gastrectomy. Three months after a distal Roux-Y gastrectomy, coupling of electromyographic recordings and jugular samples were used to perform motilin and PP radioimmunoassays during and between activity fronts (AFs) occurring in the limb and in the duodenojejunum, 20, 40, and 60 min after intragastric instillation of a standard meal (5 ml Realmentyl). Animals that underwent a simple laparotomy, animals having isolated jejunal transection, and animals with Billroth I gastrectomy (BI group) served as control groups. After Roux-Y gastrectomy, the number of AFs in the limb (P < 0.01) and in the duodenum (P < 0.001) was reduced compared to laparotomized rats and the BI group, but did not differ from the number in the Tr group. In the limb, AFs were incompletely propagated or were retrograde in 9 and 3 of 20 animals, respectively. After Roux-Y gastrectomy, motilin concentrations occurred at the same time as each duodenal AF, and as in controls, and were independent from AFs in the limb. Plasma motilin concentrations were higher after Roux-Y reconstruction than in control groups (P < 0.03), and PP level concentrations were not different. After the meal, the interruption of AFs was shorter in Roux-Y reconstruction than in laparotomized and transected animals (P < 0.05) and than in BI group, with no significant difference in the latter. In all groups, plasma motilin and PP concentrations were decreased (P < 0.05) and increased (P < 0.001), respectively, after the meal compared to the interdigestive period. After Roux-Y gastrectomy, plasma motilin and PP levels were higher (P < 0.05) and lower (P < 0.05), respectively, compared to controls. In conclusion, AFs in the Roux-Y limb were not associated with plasma motilin concentrations, suggesting a lack of influence of motilin on the interdigestive motor status. The decrease in postprandial plasma PP concentrations may play a role in the shorter interruption of AFs after a meal.

Assessment of prolonged hospital stay attributable to surgical site infections using appropriateness evaluation protocol.

BACKGROUND: The accepted standard in estimating the stay prolongation attributable to surgical site infections is the matched-cohort study method (MCS), which is associated with selection bias. The Appropriateness Evaluation Protocol (AEP) has been used to estimate stay prolongation attributable to nosocomial infections but has not been validated specifically for surgical site infections. AIM OF THE STUDY: To compare estimates of stay prolongation attributable to surgical site infections after digestive surgery, obtained by AEP and by MCS. METHODS: Sixty-five surgical site infections after digestive tract surgery were analyzed by AEP and MCS. AEP stay prolongation was the number of days judged specifically appropriate for the care of surgical site infections. MCS stay prolongation was the difference of stay duration in surgical site infection cases and two controls matched by age, sex, and diagnosis-related groups. Sensitivity and specificity of AEP, and agreement between both methods, were calculated. RESULTS: The mean AEP stay prolongation was 3.5 days vs 7.2 days for MCS. The sensitivity of AEP was 58% and the specificity was 75%. The agreement between the two methods was poor. CONCLUSION: Surgical site infections after digestive tract surgery increased the hospital stay. Accurate estimations of a prolongation of stay will vary according to the method selected.

Differential expression of apoptosis-associated genes post-hepatectomy in cirrhotic vs. normal rats.

Liver regeneration after partial hepatectomy or liver injury is controlled by a wide variety of growth factors that are proven activators or inhibitors of hepatocyte proliferation. Liver regeneration post-hepatectomy has been proven to be decreased and delayed in cirrhotic vs. normal liver. Apoptosis seems to play an important role in cellular proliferation and in liver regeneration. Therefore, this study has analyzed the expression of apoptosis-associated genes following 2/3 hepatectomy in cirrhotic vs. normal rats. Cirrhosis was induced by a weekly intragastric administration of CCl4 for 16 weeks followed by hepatectomy and histological examination of the resected liver. Rats were sacrificed at 6 h, 12 h, 24 h, or 72 h after liver resection. The expression of proapoptotic (Bad, Bak, Bax) and antiapoptotic (Bcl-2, Bcl-XL) genes was analyzed by quantitative RT-PCR. We have observed an early increase in antiapoptotic mRNA levels and a delayed increase in proapoptotic mRNA levels in normal liver following hepatectomy. Before resection, proapoptotic mRNA levels were significantly higher in cirrhotic vs. normal liver. After hepatectomy, apoptotic mRNA levels were decreased and delayed as compared with that observed following hepatectomy in normal liver. These results indicate that apoptosis takes place in liver during CCl4-induced cirrhosis and could participate in the impaired regenerative response observed in cirrhotic liver.

Motility in the Roux-Y limb after distal gastrectomy: relation to the length of the limb and the afferent duodenojejunal segment--an experimental study.

Following gastrectomy, the longer is a Roux-Y limb constructed to restore digestive continuity the higher the frequency of postoperative symptoms. The aim of this experimental study was to test how the level of the jejunal transection and the length of the Roux limb affect the motility of the constructed limb and in particular the onset and the propagation of activity fronts (AFs). Three months after a distal Roux-en-Y gastrectomy, electromyographic tracings were recorded in six groups of rats grouped according to the level of the transection (20 or 40 cm from the pylorus) and the length of the limb (10, 20 or 30 cm). Animals in which a simple laparotomy or laparotomy + jejunal transection was performed, served as controls. During the interdigestive period, all animals had AFs in the limb which were independent from those recorded in the duodenum. In the limb, the mean time interval between two AFs was shorter (P < 0.01) and more irregular than in controls. An increase in limb length was associated with a lower incidence of completely propagated AFs (P < 0.05) and a higher incidence of irregularly propagated AFs (P < 0.01). When propagation of the AFs was analysed both in the limb and in the jejunum distal to the anastomosis, propagation abnormalities were more frequent. Below the gastrojejunal anastomosis, for an intestinal length of either 20 or 30 cm, the frequency of abnormal AFs was not different when this length was either only a limb or a limb with the 10 cm of distal jejunum below the jejuno-jejunal anastomosis. Interruption of AFs by a meal was irregular in the limb and more rarely observed in the 30-cm than in 10-cm limbs (P < 0.05). Interruption of AFs was shorter than in controls (P < 0.01). In the duodenum and the jejunum proximal to the limb, the interval between AFs was higher than in controls and in the Roux-Y limbs (P < 0.001). Intraluminal concentrations of bacterial strains were not different in the different types of limb while lactobacillus concentrations and pooled concentrations of bacteria were higher than in controls (P < 0.05). No relationship was found between the incidence of myoelectric abnormalities and intraluminal bacterial concentrations. Increasing the length of a Roux-Y limb resulted in more frequent disturbances in AFs in the limb but had no significant consequence on the overall rate of abnormal AFs in the jejunum distal to the transection. Motor response to food intake was also reduced. Motor changes were not related to intraluminal bacterial concentrations.

Changes in growth factor and cytokine mRNA levels after hepatectomy in rat with CCl(4)-induced cirrhosis.

Cirrhotic liver is considered to regenerate less actively than normal liver after hepatic resection. However, the mechanisms responsible for this impaired regeneration and the cross talk of implicated factors still remain unclear. In the present study, mRNA levels for cyclins, growth factors, and cytokines were quantitatively assessed by a RT-PCR method at different times after hepatectomy in order to determine the relationships between these factors and the impaired regenerative process observed in cirrhotic liver. In our model of CCl(4)-induced cirrhosis, mRNA levels for cyclins and thymidine kinase provide evidence for the impaired and delayed hepatic regeneration. Moreover, we observed a significant decrease in interleukin (IL)-6 and tumor necrosis factor-alpha mRNA and a significant increase for IL-1beta mRNA. No significant change of hepatocyte growth factor (HGF) mRNA level was detected, contrasting with the decrease both at mRNA and protein levels in the expression of the c-Met/HGF receptor. Therefore, the impaired regeneration of the cirrhotic liver is associated not only with a lowered level of signals that normally promote liver growth but also with a strong decrease in c-Met receptor despite a normal expression of its specific ligand.

Differential regenerative response and expression of growth factors following hepatectomy of variable extent in rats.

AIMS/BACKGROUND: Liver regeneration is a physiological mechanism which leads to restoration of the hepatic parenchyma following hepatectomy or toxic injury. This process is mediated by a wide variety of cytokines and growth factors. The aim of the present study was to evaluate the influence of hepatectomy extent on the levels of intrahepatic mRNAs for cell-cycle markers and growth factors in rats submitted to a 30%, two-third or 80% hepatectomy. METHODS: Cyclins, thymidine kinase and growth factors mRNA levels were quantitatively assessed by RT-PCR at different time points post-hepatectomy (2h, 6h, 12h, days 1, 2, 6). RESULTS: As compared with a two-third hepatectomy, cyclins and thymidine kinase mRNA levels were increased but with a delayed peak at day 2 in the 80% hepatectomy group and showed a progressive increase until day 6 in the 30% hepatectomy group; mRNA levels for HGF or TGFalpha were increased with a delayed peak at 12 h or day 2 in the 80% hepatectomy group, respectively and this delay was more pronounced in the 30% hepatectomy group with a peak at day 1 or day 6. CONCLUSION: A regenerative response occurs whatever the extent of hepatectomy but the course of regeneration and expression of growth factors differs according to the volume of resected liver. A better knowledge of these events could improve the clinical results of hepatic resection for primary or metastatic liver disease.

Upper jejunal motility after pancreatoduodenectomy according to the type of anastomosis, pancreaticojejunal or pancreaticogastric.

BACKGROUND: The goal of this study was to compare upper jejunal motor patterns after Billroth II pancreatoduodenectomy according to the type of pancreatic anastomosis (pancreaticojejunostomy [PJA] or pancreaticogastrostomy [PGA]) and the presence or absence of postoperative symptoms. STUDY DESIGN: Manometric recordings during fasting and after a 750-kcal meal were performed in the afferent limb in 12 patients (7 PJA, 5 PGA) and in the efferent limb in 15 other patients (7 PJA, 8 PGA) with a postoperative delay of 15+/-6 days and 3.9+/-2.2 months respectively. Patient data were compared to those of 20 healthy controls. RESULTS: During fasting, the 2 main abnormal findings were a higher incidence (p < 0.05) and a slower migration velocity (p < 0.01) of incomplete phase III by comparison with that recorded in controls. No difference for phase III was observed between the 2 surgical procedures regardless of recording site. Trimebutine, 100 mg intravenously, induced a phase III in 89% (24 of 27) of the patients. Delay of motor response varied from 5 to 10 minutes without difference between the recording site; it was less than 2 minutes in 100% of controls. Trimebutine-induced phase III showed similar propagation abnormalities to the spontaneous phase III. Duration of the fed pattern (p < 0.001) and motor index (p < 0.001) were significantly lower than in controls after the meal, in both limbs, whatever the type of anastomosis. Differences between the 2 surgical procedures were a slower migration velocity of phase III (p < 0.01) and a lower postmeal motor index (p < 0.05) in the efferent limb after PJA than after PGA. Nine of 27 patients were symptomatic. In these 9 patients, mean phase III migration velocity was slower (p < 0.001), and mean area under the postprandial curve was higher (p < 0.01) than in asymptomatic patients. Propagated clusters of contractions were only found in symptomatic patients and in the afferent limb. CONCLUSIONS: Pancreatoduodenectomy is associated with significant motor disturbances, mainly slower phase III and a reduced fed pattern, in the upper jejunum, at least during the first 3 postoperative months. Few motor differences were observed between PGA and PJA pancreatic anastomosis. A lesser occurrence of postsurgical motor anomalies does not appear to be an argument for preferring PGA to PJA.

Ileoanal anastomosis for ulcerative colitis: results of an evolutionary surgical procedure.

BACKGROUND/AIMS: Proctocolectomy with ileoanal anastomosis (IAA) has proved to be the most suitable surgical treatment for ulcerative colitis. The aim of this study was to compare the results of IAA according to the evolution of surgical procedures and particularly to compare the results of stapled versus hand-sewn anastomosis. METHODOLOGY: From 1984 to 1996, 37 men and 31 women were operated on in our centre for ulcerative colitis. The anastomosis between the J pouch and the dentate line was handsewn in 35 patients (group 1) and stapled in 33 patients (group 2). RESULTS: The mean operative time was significantly shorter in group 2 as compared with group 1 (265+/-59 vs. 323+/-53, p<0.01, respectively), whereas morbidity and functional results were comparable in both groups. In 10 patients with stapled IAA, a diverting ileostomy was not performed and the morbidity in this group did not increase. CONCLUSIONS: These results suggest that stapled IAA anastomosis is a safe procedure. The stapling technique of IAA simplifies total excision of the rectum and could mean that a diverting ileostomy is not necessary.