Total Gastrectomy with Roux-en-Y Limb Reconstruction for Complex and Chronic Fistulas After Laparoscopic Sleeve Gastrectomy: Single-Center Experience.

PURPOSE: When a leak after laparoscopic sleeve gastrectomy (LSG) becomes a chronic fistula, the best surgical treatment remains controversial. The aim of study was to review our experience concerning the treatment of chronic and complex fistulas after LSG. MATERIALS AND METHODS: A retrospective analysis of patients with a gastric fistula following LSG who were treated at our center between January 2013 and December 2018 was performed. All patients included underwent a total gastrectomy with a Roux-en-Y reconstruction (TG) for LSG chronic fistula. RESULTS: During the period considered, 13 patients had a chronic fistula and were treated with open TG. The primary leak evolved to a gastro-cutaneos fistula in three patients (23%), to a gastro-splenic fistula in two patients (15.4%), to a gastro-pleural fistula in four patients (30.8%), and to a gastro-bronchial fistula in four patients (30.8%). During TG, a splenectomy and a spleno-pancreatectomy were needed in the two cases of gastro-splenic fistula. Five patients (38.5%) developed an early complication. Two patients developed an esophago-jejunal anastomotic leak treated with a conservative approach (15.4%). No patients needed hospitalization in the intensive care unit. Overall mean length of stay was 19 days (8-30 days). Mean BMI before LSG was 36 (± 5 kg/m2), mean BMI before TG was 30.3 (± 5.2 kg/m2), and mean BMI 2 years after TG was 23.5 (± 2.9 kg/m2). CONCLUSION: When a more conservative and less mutilating surgical option is not possible, open TG with esophago-jejunostomy remains a valuable salvage procedure in the case of complex and extensive fistulas after LSG.

Correction to: Ileocolic intussusception due to a cecal endometriosis: Case report and review of literature.

After publication of this work [1], the authors noticed that the first names and last names of all the authors were inverted. In the original manuscript, they appear on PubMed as.

Laparoscopic sleeve gastrectomy after failed gastric banding: is it really effective? Six years of follow-up.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become a valuable surgical option to rescue laparoscopic adjustable gastric banding (LAGB) failures. OBJECTIVES: The aim of this study was to determine whether conversion to LSG after failed LAGB (CLSG) is a well-tolerated and effective rescue procedure compared with primary LSG (PLSG) in the long term. SETTING: University hospital, France. METHODS: A retrospective review of data concerning consecutive patients receiving a LSG between February 2008 and December 2014 was conducted. Mortality, postoperative complications, and weight loss outcomes were analyzed. RESULTS: Of 701 LSG, 601 (85.7%) were PLSG and 100 (14.3%) were CLSG. The mortality rate was 0%. Overall morbidity was comparable between the primary and conversion group (10% versus 6%, P = .27). The mean percentage of excess weight loss at 3, 36, and 72 months was 34.9%, 72.1%, and 57.2% after PLSG and 22.6%, 51.2% and 29.8% after CLSG (P<.05). The failure rate (mean percentage of excess weight loss<50%) was higher in the CLSG group during the first 5 postoperative years (P < .001) with more than two thirds of the CLSG considered as having failed at 60 months. Patients who underwent band ablation as a result of insufficient weight loss or weight regain presented the worst results after conversion to LSG. CONCLUSION: In this study, the conversion of failed LAGB to LSG in 2 steps indicated a safety profile comparable to that of primary LSG but was significantly less effective from the early postoperative course (3 mo) up to 6 years postoperatively. CLSG may not be the best option because a third operation may be needed as a result of insufficient weight loss.

Long-Term Outcomes of the Laparoscopic Adjustable Gastric Banding: Weight Loss and Removal Rate. A Single Center Experience on 301 Patients with a Minimum Follow-Up of 10 years.

BACKGROUND: Obesity is a chronic disease that requires procedures to enable to maintain good long-term results. Laparoscopic adjustable gastric banding (LAGB) studies with a long-term follow-up are limited and have often given conflicting results. We report our results in terms of banding life span and weight loss in a cohort of 301 patients operated on LAGB with a minimum follow-up of 10 years. METHODS: All patients who underwent LAGB at our university hospital between 1998 and 2004 were included in this study. The main outcome was band survival and complications that led to band removal, and the secondary outcome was weight loss. We present raw data and data after imputation for patients lost at follow-up. RESULTS: Most patients were women (83 %), and the mean body mass index (BMI) baseline was 45.2 ± 6.7. The pars flaccida technique was performed in 50.9 % of the patients. All patients had at least 10 years of follow-up (range 10-16 years). Data were available at 10 years for 79.7 % and at 15 years for 80.6 %. Band survival was 65.8 % at 10 years and 53.3 % at 15 years. Mean excess weight loss (EWL) at 5, 10, and 15 years was 41.4, 38.7, and 35.1 %, respectively. CONCLUSION: Despite the encouraging short-term results, LAGB shows long-term disappointing results in terms of weight loss and complication rates. The removal rate increases with time (about 3-4 % per year), and at 15 years, almost half of the bands had been removed.

Rare Neurological Complications After Sleeve Gastrectomy.

BACKGROUND: Bariatric surgery is considered to be the most effective treatment of morbid obesity and improvement of obesity-related comorbidities, such as type II diabetes. However, both peripheral and central neurological complications can occur after bariatric surgery. Such complications tend to occur more frequently after bypass surgery than after sleeve gastrectomy (SG). The objective of this study was to identify the patients that presented post-operative neurological complications after undergoing SG and describe the incidence, presentation, and management of these complications. METHODS: This was a retrospective study of 592 cases of SG performed between 2009 and 2014 with a special focus on patients who presented neurological complications. RESULTS: Of the 592 SG cases, only seven (1.18 %) patients presented neurological complications. All patients had uneventful post-operative course, but all reported feeding difficulties, accompanied by severe dysphagia, and rapid weight loss, with a mean weight loss of 35 kg (30-40 kg) 3 months after SG. All patients were readmitted owing to neurological symptoms that included paresthesia, abolition of deep tendon reflexes of the lower limbs, muscle pain, and motor and sensitive deficits in some cases. There were two cases of Wernicke's encephalopathy. All patients were treated for neuropathy secondary to vitamin B1 deficiency and had a significant improvement and/or resolution of their symptoms. CONCLUSIONS: Neurological complications after SG are rare and are often preceded by gastrointestinal symptoms, rapid weight loss, and lack of post-operative vitamin supplementation. Re-hospitalization and multidisciplinary team management are crucial to establish the diagnosis and initiate treatment.

Inguinal Hernia Repair Using Self-adhering Sutureless Mesh: Adhesix™: A 3-Year Follow-up with Low Chronic Pain and Recurrence Rate.

To review our experience and outcomes after inguinal hernia repair using the lightweight self-adhering sutureless mesh "Adhesix™" and demonstrate the safety and efficacy of this mesh. This is a 3-year retrospective study that included 143 consecutive patients who underwent 149 inguinal hernia repairs at our department of surgery. All hernias were repaired using a modified Lichtenstein technique. Preoperative, perioperative, and postoperative data were prospectively collected. Incidence of chronic pain, postoperative complications, recurrence, and patient satisfaction were assessed three years postoperatively by conducting a telephone survey. We had 143 patients with a mean age of 58 years (17-84), who underwent 149 hernia repairs using the Adhesix™ mesh. Ninety-two per cent (131 patients) were males. Only 10 patients (7%) had a postoperative pain for more than three years. In our series, neither age nor gender was predictive of postoperative pain. Only one patient had a hematoma lasting for more than one month and only four patients (2.8%) had a recurrence of their hernia within three years of their initial surgery. Ninety per cent of the patient expressed their satisfaction when surveyed three years after their surgery. In conclusion, the use of the self-adhering sutureless mesh for inguinal hernia repair has been proving itself as effective as the traditional mesh. Adhesix™ is associated with low chronic pain rate, recurrence rate, and postoperative complications rate, and can be safely adopted as the sole technique for inguinal hernia repair.

Two stages conversion of failed laparoscopic adjustable gastric banding to laparoscopic roux-en-y gastric bypass. A study of one hundred patients.

INTRODUCTION: Conversion to laparoscopic gastric bypass (LRYGB) appears to be the treatment of choice after failed LAGB. To reduce the risk of postoperative complications, some surgeons routinely adopt a two-stage strategy. The purpose of this study was to analyze our institution's experience with the two-stage procedure for LAGB conversion to LRYGB MATERIALS AND METHODS: The bariatric database of our institution was reviewed to identify patients who had undergone conversion of LAGB to LRYGB from November 2007 to June 2012. RESULTS: One hundred patients were included. Of these, 62 (62%) required conversion to LRYGB for inadequate weight loss or weight regain and 38 for band-related complications. All the procedures were performed in two stages and laparoscopically. The average time between band removal and LRYGB was 17.3 months. The mean follow-up after LRYGB was 31 ± 18.7 months. The mean BMI prior to LRYGB conversion was 45.3 ± 5.2. Early complications occurred in 15 patients (15%), while late complications occurred in only 3 patients (3%). The average %EWL at 24 months and 48 months after conversion was 70.1 and 69.4%, respectively. CONCLUSION: Although a two-stage conversion strategy increases the number of operations and hospital stay without decreasing the rate of early complications compared to one-stage conversion; it has shown to be associated with low rates of GJA stenosis and excellent %EWL.

Two-step conversion surgery after failed laparoscopic adjustable gastric banding. Comparison between laparoscopic Roux-en-Y gastric bypass and laparoscopic gastric sleeve.

BACKGROUND: Despite its worldwide popularity, laparoscopic adjustable gastric banding (LAGB) requires revisional surgery for failures or complications, in 20-60% of cases. The purpose of this study was to compare in terms of efficacy and safety, the conversion of failed LAGB to laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy. (LSG). METHODS: The bariatric database of our institution was reviewed to identify patients who had undergone conversion of failed LAGB to LRYGB or to LSG, from November 2007 to June 2012. RESULTS: A total of 108 patients were included. Of these, 74 (68.5%) underwent conversion to LRYGB and 34 to LSG. All of the procedures were performed in 2-stage and laparoscopically. The mean follow-up for the LRYGB group was 29.1±17.9 months while for the LSG patients was 24.2±14.3 months. The mean body mass index (BMI) prior LRYGB and LSG was 45.6±7.8 and 47.5±5.6 (P = .09), respectively. Postoperative complications occurred in 16.2% of the LRYGB patients and in 2.9% of the LSG group (P = .04). Mean percentage of excess weight loss was 59.9%±16.2% and 70.2%±16.7% in LRYGB, and it was 52.2%±11.4% and 59.9%±14.4% in LSG at 12 months (P = .007) and 24 months (P = .01) after conversion. CONCLUSION: In this series, LRYGB and LSG are both effective and adequate revisional procedure after failure of LAGB. While LRYGB seems to ensure greater weight loss at 24 months follow-up, LSG is associated with a lower postoperative morbidity.

Intraperitoneal tension-free repair of a small midline ventral abdominal wall hernia: randomized study with a mean follow-up of 3 years.

Funding received from Cousin Biotech, Wervicq Sud, France, and CR Bard Inc., Cranston, RI. The aim of this prospective randomized study was to determine the long-term recurrence and complication rates after small abdominal wall hernia repair with two different bilayer prostheses. Hernia repair using prosthetic mesh material has become the preferred method of repair, because the recurrence rates are much lower than with conventional repair techniques. The use of a hernia bilayer patch, composite expanded polytetrafluoroethylene (ePTFE)-polypropylene, with intraperitoneal placement behind the hernia defect, through a small incision, may be efficient, safe, and cost-effective. This study is a randomized, single-institution trial, including 83 selected consecutive patients with primary (umbilical, epigastric) or incisional anterior abdominal wall defects from 2 to 5 cm. Hernia repair was performed by direct local access in ambulatory surgery; the prosthesis used was a circular bilayer with an inner face in ePTFE to avoid bowel adhesion. One group was treated with a Ventralex® Hernia Patch (Bard USA). The second group was treated with a Cabs'Air® Composite (Cousin Biotech France), which was delivered with two to four fixation sutures and a balloon to properly deploy the mesh intraperitoneally. Patients' characteristics and operative and postoperative data were prospectively collected. The primary outcome was late recurrence. Secondary outcomes included, pain, discomfort and quality of life before and after (3 months) surgery using the SF-12 questionnaire, patient-surgeon satisfaction, and early and late complications. Among 98 patients, 83 were included in the study protocol between January 2007 and August 2011. The two groups were comparable according to pre- and intraoperative data. According to surgeon experience, placement of the Cabs'Air® device was significantly faster (P = 0.01) and easier. At 3 months, there was significantly less pain and less discomfort for the Cabs'Air® group and patient satisfaction rate was higher. This was confirmed by all components of the SF-12 questionnaire. Long-term follow-up was available for 77 patients. The mean follow-up was similar for the two groups (42 months; range, 14 to 70 months). At this point, for the Ventralex® group, there were four recurrences (11.7%); one mesh infection; one small bowel obstruction; and six cases (15.7%) of severe pain resulting from a mass syndrome (shrinkage) with a sense of the presence of a foreign body. Six reoperations (15.6%) were required with explant of the prosthesis. There were no recurrences or late complications in the comparative group. The Ventralex® Hernia Patch is associated with inconsistent deployment, spreading, or shrinkage, which account for late complications and decreases the overlap, which contributes to the recurrence rate. The Cabs'Air®-associated balloon facilitates superior deployment of the prosthesis allowing for good fixation with four sutures.

Hepatic endometrioma: a case report and review of the literature: report of a case.

Hepatic endometriosis has an extremely rare occurrence characterized by the presence of ectopic endometrium in the liver. A diagnosis of hepatic endometriosis is established after surgery. A 51-year-old multiparous female was referred to our unit for investigation of a liver tumor. The patient reported a 6-month history of epigastric pain and vomiting. She had undergone conservative hysterectomy for uterine leiomyomas several years earlier. The results of liver function tests and the levels of tumor markers (CA 19.9, CEA, CA125, αFP) were normal. Radiological imaging (USS, CT and MRI) suggested the presence of liver cystadenoma, liver cystadenocarcinoma or cystic metastasis of the liver in the left liver lobe extending to the diaphragm with left hepatic vein compression. Laparotomy was performed. The intraoperative frozen sections suggested a diagnosis of endometriosis. Anatomical resection was performed, including left lobectomy with diaphragm resection. The final histology confirmed the presence of hepatic endometrioma without malignant transformation. Fourteen cases of hepatic endometrioma have been described in the medical literature. We herein report the 15th case. Making a preoperative diagnosis of hepatic endometriosis is very difficult, despite conducting a complete investigation, in the absence of clinical and radiological characteristics. The diagnosis is made according to a histological examination of the whole surgical sample.

Ileocolic intussusception due to a cecal endometriosis: case report and review of literature.

UNLABELLED: Cecal endometriosis and ileocolic intussusception due to a cecal endometriosis is extremely rare. We report a case of a woman who presented an ileocecal intussusception due to a cecal endometriosis. The patient gave two months history of chronic periombilical pain requiring regular hospital admission and analgesia. The symptoms were not related to menses. A laparotomy was performed and revealed an ileocolic intussusception. The abdominal exploration did not find any endometriosis lesion. Ileocaecal resection was performed. Microscopic examination showed a cystic component, lined by a regular cylindric epithelium. Foci of endometrial tissue were observed in the cecal subserosa and muscularis mucosal, with irregular endometrial glands lined by cylindric epithelium without atypia immunostained with CK7, and characteristic endometrial stroma immunostained with CD10. Cecal endometriosis and ileocolic intussusception due to a cecal endometriosis is extremely rare. Diagnose of etiology remains challenging due to the absence of clinical and radiological specific characteristics. VIRTUAL SLIDE: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/2975867306869166.

Prolonged paradoxical response to anti-tuberculous treatment after infliximab.

A 56-year-old woman with ankylosing spondylitis, treated for 3 months with infliximab, developed miliary tuberculosis with mediastinal lymphadenopathies and brain and splenic lesions. After initial improvement under anti-tuberculous therapy, she suffered an unexpectedly prolonged paradoxical worsening with several episodes of lymphadenopathy, including life-threatening ones, over a period of more than 14 months of follow-up. The outcome was favorable as a result of corticosteroid and surgical treatments. This phenomenon reflects a paradoxical reaction precipitated by infliximab withdrawal.

Video-assisted versus conventional tracheal intubation in morbidly obese patients.

BACKGROUND: We compared tracheal intubation characteristics and arterial oxygenation quality during airway management of morbidly obese patients whose trachea was intubated under video assistance with the LMA CTrach (SEBAC, Pantin, France) or the Airtraq laryngoscope (VYGON, Ecouen, France) with that of the conventional Macintosh laryngoscope. METHODS: After standardized induction of anesthesia, 318 morbidly obese patients scheduled for elective morbid obesity surgery received tracheal intubation with the LMA CTrach, the Airtraq laryngoscope, or the conventional Macintosh laryngoscope. Duration of apnea, time to tracheal intubation, and oxygenation quality during airway management were compared between the LMA CTrach and the laryngoscope groups. RESULTS: Patients' characteristics were similar in the three groups. The success rate for tracheal intubation was 100% with the LMA CTrach and the Airtraq laryngoscope. One patient of the Macintosh laryngoscope group received LMA CTrach intubation because of early arterial oxygen desaturation associated with unstable facemask ventilation. The duration of apnea was shorter with the LMA CTrach than that of the Airtraq laryngoscope and the Macintosh laryngoscope. The duration tracheal intubation was shorter with the Airtraq laryngoscope than with the Macintosh laryngoscopes and the LMA CTrach. During airway management, arterial oxygenation was of better quality with the LMA CTrach and the Airtraq laryngoscope than that of the Macintosh laryngoscope. CONCLUSION: Because LMA CTrach promoted short apnea time and the Airtraq laryngoscope allowed early definitive airway, both video-assisted tracheal intubation devices prevented most serious arterial oxygenation desaturation evidenced during tracheal intubation of morbidly obese patients with the conventional Macintosh laryngoscope.

Laparoscopic appendectomies: retrospective study of 2074 cases.

PURPOSE: To determine feasibility and safety of laparoscopic appendectomy (LA). PATIENTS: From January 1991 to June 2006, 2209 consecutive patients underwent appendectomy; for 2074 patients, appendectomy was performed laparoscopically. One thousand and fifty (53%) were women; mean age was 30.8 (11 to 96) years. Mean body mass index was 23.6 (18 to 58 kg/m2). Mean American Society of Anesthesiology score was 1.3 (I to III). RESULTS: Mean operating time was 52 minutes (15 to 200). Conversion to open appendectomy occurred for 84 patients (3.6%) mainly for acute or generalized peritonitis, abscess, or adhesion. Mean hospital stay was 3.75 (1 to 27) days. There was no mortality. Morbidity occurred in 4.5% of the patients: parietal (1.15%), peritoneal complications (1.1%), and others (2.25%). Additional interventions were required for 30 patients (1.5%) primarily for residual abscesses. In this study, 10.9% (n=226) of the specimens were considered normal by the pathologist. In 3.9% (77 cases), laparoscopy did not find any cause for nonspecific abdominal pain. In these cases, appendix was not removed. CONCLUSIONS: LA is technically feasible and safe. Diagnostic laparoscopy is recommended in cases suspicious for acute appendicitis. Laparoscopy permits a complete exploration of the abdominal cavity, helps to localize the appendix, allows for the eliminations of other diagnoses when the appendix is normal, and to facilitate a better peritoneal lavage in case of peritonitis. It is recommended to perform LA routinely in young women and obese. Although advantages of LA still need to be evaluated, in view of the excellent results, we have decided to perform it routinely. We also recommend not removing macroscopically normal appendices discovered during diagnostic laparoscopy for abdominal pain of unexplained origin.

Quality of life after laparoscopic gastric banding: Prospective study (152 cases) with a follow-up of 2 years.

To evaluate influence of laparoscopic gastric banding (LGB) on quality of life (QOL) in patients with morbid obesity. Laparoscopic adjustable gastric banding is a popular bariatric operation in Europe. The objectives of surgical therapy in patients with morbid obesity are reduction of body weight, and a positive influence on the obesity-related comorbidity as well the concomitant psychologic and social restrictions of these patients. In a prospective clinical trial, development of the individual patient QOL was analyzed, after LGB in patients with morbid obesity. From October 1999 to January 2001, 152 patients [119 women, 33 men, mean age 38.4 y (range 24 to 62), mean body mass index 44.3 (range 38 to 63)] underwent evaluation for LGB according the following protocol: history of obesity; concise counseling of patients and relative on nonsurgical treatment alternatives, risk of surgery, psychologic testing, questionnaire for eating habits, necessity of lifestyle change after surgery; medical evaluation including endocrinologic and nutritionist work-up, upper GI endoscopy, evaluation of QOL using the Gastro Intestinal Quality of Life Index (GIQLI). Decision for surgery was a multidisciplinary consensus. This group was follow-up at least 2 years, focusing on weight loss and QOL. Mean operative time was 82 minutes; mean hospital stay was 2.3 days and the mean follow-up period was 34 months. The BMI dropped from 44.3 to 29.6 kg/m and all comorbid conditions improved markedly: diabetes melitus resolved in 71% of the patients, hypertension in 33%, and sleep apnea in 90%. However, 26 patients (17%) had late complications requiring reoperation. Preoperative global GIQLI score was 95 (range 56 to 140), significant different of the healthy volunteers score (120) (70 to 140) P < 0.001. Correlated with weight loss (percentage loss of overweight and BMI), the global score of the group increased to 100 at 3 months, 104 at 6, 111 at 1 year to reach 119 at 2 years which is no significant different of healthy patients. Analyzing the subscale, physical condition, emotional status, and social integration increased significantly (P < 0.001) from preoperative to end of follow-up. Digestive symptoms were not modified. In case of failure of the procedure (10.5%) global Giqli score is not modified. Patients who have required successful revisional surgery for late complications (6.5%) have an excellent QOL outcome that are not different from the whole group. Together with a satisfactory reduction of the excess overweight, laparoscopic gastric banding may lead in a carefully selected population of patients with morbid obesity to a significant improvement of patient QOL, in at least 2 years follow-up.

Laparoscopic resection of low rectal cancer with a mean follow-up of seven years.

The role of laparoscopic surgery in the management of cancer of the rectum remains controversial. The main concern is the risk of port-site metastasis and neoplastic dissemination. The aim of this study was to evaluate prospectively 29 patients who underwent laparoscopic resection with total mesorectum excision for lower rectal carcinoma with a mean follow-up of 7 years. From January 1993 to December 1998, 29 patients with proven low (<10 cm from the anal verge) rectal cancer were operated by a laparoscopic approach. They were followed up at 1-, 3-, and then every 6-month intervals, postoperatively for an average of 7 years. Mean operative time was 157 +/- 46 minutes. The conversion rate was 13.7% (4 cases): 1 for tumor invasion of adjacent structures, 2 for inadequate margins of resection, and 1 for locally advanced cancer. First flatus occurred after 37.3 +/- 11.5 hours, and oral feeding started at 48.3 +/- 23 hours postoperatively. The length of the suprapubic incision for extraction of the specimen was 5.6 +/- 1.7 cm. Hospital stay was 7.2 +/- 3.0 days. There were no deaths. The morbidity rate was 14.8%. Length of the specimen, lateral and distal margins, and the number of lymph nodes resected were comparable to those of an open surgical approach. The average postoperative follow-up was 7 years (5-10 years). The late complication rate was 3.7%. There were no port-site metastases. Five-year recurrence rates were 0%, 22%, and 37% for Duke's A, B, and C cancers, respectively. The 5-year survival rate was 100% for Duke's A, 89% for B, and 50% for C. Laparoscopic resection for low rectal cancer with total mesorectum excision can be performed with the same oncologic principles, low morbidity, and long-term complications. Five-year survival and recurrence rates are comparable to those of open surgery.