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Introduction. Laparoscopic Sleeve Gastrectomy (SG) is considered as successful if the percentage of Excess Body Mass Index Loss (% EBMIL) remains constant over 50% with long-term follow-up. The aim of this study was to evaluate whether early % EBMIL was predictive of success after SG. Methods. This retrospective study included patients who had SG with two years of follow-up. Patients had follow-up appointments at 3 (M3), 6, 12, and 24 months (M24). Data as weight and Body Mass Index (BMI) were collected systematically. We estimated the % EBMIL necessary to establish a correlation between M3 and M24 compared to % EBMIL speeds and calculated a limit value of % EBMIL predictive of success. Results. Data at operative time, M3, and M24 were available for 128 patients. Pearson test showed a correlation between % EBMIL at M3 and that at M24 ( r = 0.74; p < 0.0001). % EBMIL speed between surgery and M3 ( p = 0.0011) was significant but not between M3 and M24. A linear regression analysis proved that % EBMIL over 20.1% at M3 ( p < 0.0001) predicted a final % EBMIL over 50%. Conclusions. % EBMIL at M3 after SG is correlated with % EBMIL in the long term. % EBMIL speed was significant in the first 3 months. % EBMIL over 20.1% at M3 leads to the success of SG., Competing Interests: None of the authors (Guillaume Philouze, Emmanuel Huet, Antoine Gancel, Gaëtan Prévost, Michael Bubenheim, and Michel Scotté) declared any conflict of interests.

Recurrence after hepatocellular carcinoma (HCC) is frequent. Currently, there are no recommendations on therapeutic strategy after recurrence of HCC. Whereas the 5 year-recurrence rate after resection of HCC is 100%, this drops to 15% after primary liver transplantation. Repeat hepatectomy and salvage liver transplantation (SLT) could be performed in selected patients to treat recurrent HCC and enable prolonged overall survival after treatment of recurrence. Other therapies such as local ablation, chemoembolization or sorafenib could be proposed to those patients unable to benefit from resection or SLT. A clear definition of the place of SLT and "prophylactic" liver transplantation is required. Indeed, identifying risks factors for recurrence at time of primary liver resection of HCC may help to avoid recurrence beyond Milan criteria and non-resectable situations. In this review, we summarize the recent data available in the literature on the feasibility and outcomes of repeat hepatectomy and SLT as treatment for recurrent HCC.

Background: Management of perforated gastro-duodenal ulcer (GDU) is not consensual, from no operative treatment to surgery by simple closure, gastrectomy and vagotomy. The purpose of this study is to report results of the literature concerning management of perforated GDU., Methods: Two authors, identified in the databases Pubmed and Embase studies, related to the therapeutic management of perforated GDU. The data were extracted from articles published between 1940 and 2012., Results: Non-operative treatment is feasible for patients in good general condition and in good local circumstances without evolved peritonitis with a success rate more than 50%. Simple closure is the standard method. Laparoscopy is a safe and feasible method for patient with delay of treatment less than 24 hours and without associated complications with a success (meaning non conversion) of 80% and a mortality less than 1%. Rate of conversion is 7.9%, and increases in case of ulcer size >6 mm, frail ulcer edges, bleeding associated, unusual location and septic shock. Helicobacter pylori eradication is essential. Gastric tube, abdominal irrigation and drainage are still debated. Two-stage treatment for perforated gastric carcinoma, which represents 10 to 16% of gastric perforation, is a good option for frail patients with resectable tumors., Conclusion: Management of perforated GDU is still a subject of debate without guidelines but with several possibilities of treatment depending of local circumstances of peritonitis and size of defect >20 mm, general conditions, surgeon patterns and experience., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Sorafenib is a molecular-targeted therapy used in palliative treatment of advanced hepatocellular carcinoma (HCC) in Child-Pugh A patients. We describe the case of a patient who presented with a large HCC in the left liver associated with portal vein thrombosis (PVT). After 9 months of sorafenib treatment, reassessment showed that the tumors had decreased in size with recanalization of the portal vein. A lateral left hepatectomy was performed and pathology showed complete necrosis of the tumor. Sorafenib can downstage HCC in patients with cirrhosis allowing further surgical resection.

The incidence of complications after hepatectomy has been considerably reduced over the last 20 years. Better knowledge of liver anatomy and liver regeneration, and methods preventing bleeding during surgery have resulted in morbidity rates below 20% and mortality rates less than 5%. The treatment of the liver cross section remains controversial. Experimental studies have reported convincing biological effects of fibrin sealants or compresses when applied on the liver to decrease hemorrhagic or biliary complications. However, clinical studies are very heterogeneous, providing conflicting results compromising recommendations for routine use., (Copyright © 2011. Published by Elsevier Masson SAS.)

Background: Only limited data has been reported so far regarding oesophageal cancer (EC) in elderly patients. The aim of the study is to identify the baseline parameters that influenced therapeutic decision., Methods: All consecutive patients 70 years or older being treated for EC were retrospectively analyzed. Patients without visceral metastasis were divided into two groups: treatment with curative intent (chemoradiotherapy, surgery, radiotherapy, mucosectomy or photodynamic therapy) or best supportive care (BSC). Patients with metastasis were divided into two groups: palliative treatment (chemotherapy, chemoradiotherapy or radiotherapy) or BSC., Results: Two hundred and eighty-two patients were studied. Mean age was 76.5 ± 5.5 years and 22.4% of patients had visceral metastasis. In patients without visceral metastasis (n = 220) the majority had treatment with curative intent (n = 151) whereas in patients with metastasis (n = 62) the majority had BSC (n = 32). Severe adverse events (≥ grade 3) were observed in only 17% of the patients. Patients without specific carcinologic treatment were older, had more weight loss, worse WHO performance status and Charlson score in multivariate analysis., Discussion: Our results suggest that elderly patients with an EC could benefit from cancer treatment without major toxicities. Weight loss, WHO performance status and the Charlson score could be used to select the appropriate treatment in an elderly patient.

Perforation of rectal cancer usually occurs intraperitoneally. Extraperitoneal perforation is rare and usually presents as perineal sepsis, leading to diagnosis and urgent surgical management plus antibiotic therapy. We report the case of a patient presenting with a perforated rectal carcinoma which presented as necrotizing fasciitis of the right thigh., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

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.

Partial hepatectomy (PH)-induced Kupffer cell (KC) activation results in a rapid release of cytokines inducing the acute-phase response (APR). This study was done to evaluate the role of Kupffer cells (KCs) in the course of the APR following PH and a consecutive endotoxin challenge. KC depletion was performed in rats by i.v. administration of 1 mL liposome-encapsulated dichloromethylene diphosohonate (Cl2MDP). Control rats received 1 mL NaCl 0.9%. Forty-eight hours later, PH was performed. At 24 h after PH, rats were randomized to receive either 1 mL NaCl 0.9% (saline) or 50 microg/kg LPS i.v. in 1 mL. Animals were sacrificed at 4 h after LPS or saline infusion. The APR was determined by measuring hepatic gene expression of alpha 2-macroglobulin, alpha 1-acid glycoprotein, and IL-6 and expression of hepatic albumin. The APR was significantly depressed in KC-depleted rats. Despite increased IL-6 mRNA synthesis in response to low-dose LPS, no enhancement of acute-phase protein synthesis (APP) was found in KC-depleted rats. Hepatic failure was most profound in KC-depleted rats, as indicated by elevated plasma levels of liver transaminases and ammonia. We conclude that after PH, KC function in the remnant liver is important for the acute-phase reaction and reduces endotoxin-induced hepatocyte damage.

This prospective study investigated the role of reduced hepatic synthesis of regulating proteins in coagulopathy after partial hepatectomy (PH) compared with major abdominal surgery (MAS) without involvement of the liver. Furthermore, we studied the effect of rBPI21, an endotoxin-neutralizing agent, on coagulopathy after PH was studied. Compared with MAS, PH resulted in significantly elevated levels of thrombin-antithrombin-III and plasmin-alpha2-antiplasmin complexes. Levels of antithrombin-3, alpha2-antiplasmin, fibrinogen, plasminogen, alpha2-macroglobulin (alpha2-M), and C1-inhibitor remained lower following PH. Treatment with rBPI21 led to significantly lower levels of tissue-type plasminogen activator (t-PA). Post-operative disseminated intravascular coagulation (DIC) was associated with significantly higher bilirubin and t-PA plasma levels and significantly lower levels of alpha2-M. This study indicates that PH induced hepatic failure results in decreased synthesis of hepatic regulating plasma proteins and subsequent activation of coagulation and fibrinolysis. Prevention of t-PA release by rBPI21 may have important clinical implications. Decreased availability of alpha2-M may be a factor in post-operative DIC.

Acute-phase protein synthesis in the liver during inflammation is regulated via cytokines and glucocorticoids. Using quantitative reverse transcription (RT)-PCR analysis and immunoassay, we explored, in the rat, the response of the acute-phase protein, alpha-2 macroglobulin (A2M), after systemic inflammation induced by lipopolysaccharide (LPS) or localized inflammation induced by turpentine oil (TO). The results indicate that synthesis of A2M is higher following TO-induced inflammation than LPS-induced inflammation and is not correlated with interleukin (IL)-6 or glucocorticoid levels. We studied the putative role of heme in this differential A2M expression following localized vs. systemic inflammation; addition of heme during LPS-induced inflammation can boost the expression of A2M, whereas blocking heme synthesis (by succinyl acetone) or enhancing its consumption in parallel biosynthetic pathways (cytochrome P450 induction by phenobarbital) decreases A2M expression. This decrease was abolished by exogenous heme supplementation. Finally, we demonstrate that heme supplementation is also able to increase the A2M response in female rats to a level similar to that in male rats providing a new insight into the puzzling sexual dimorphism observed previously during localized inflammation. We propose that heme should be considered a new regulatory element in controlling liver A2M expression during inflammation.

The acute-phase protein (APP) response is regulated by cytokines such as interleukin-6 (IL-6), interleukin-1 (IL-1) and tumor necrosis factor (TNF), but may also be influenced by malnutrition. The aims of this study were as follows: 1) to determine in rats the effect of a protein-deficient diet on IL-6 mRNA expression in intestine, liver and peripheral blood mononuclear cells (PBMC), and on alpha-1 acid glycoprotein (AGP) and alpha-2 macroglobulin (A2M) serum levels and hepatic mRNA expression; 2) to compare, in protein-deficient rats, the IL-6 and APP responses after a turpentine (TO)- or a lipopolysaccharide (LPS)-induced inflammation; and 3) to determine the effect of a protein malnutrition on IL-6 mRNA expression in rat PBMC treated ex vivo with LPS. Interleukin-6 mRNA was present in intestine and PBMC but not in the liver of malnourished rats, and was absent in any tissue or cells of controls. A2M was present in the serum from malnourished rats but not after refeeding. AGP mRNA expression was not influenced by protein malnutrition. In malnourished rats, IL-6 serum level peaked later than in controls after TO and LPS treatment. In malnourished TO-treated rats, A2M mRNA increased earlier than in controls and remained detectable later than in controls. AGP mRNA expression after TO was not influenced by protein malnutrition. In PBMC of malnourished rats, LPS-induced IL-6 mRNA expression occurred earlier and lasted longer than in controls. Our results indicate that protein malnutrition by itself induces IL-6 and A2M expression, and that it modulates the APP response to inflammation.

Interleukin 6 (IL-6), tumour necrosis factor alpha (TNF-alpha), interleukin 1 (IL-1), and transforming growth factors alpha and beta (TGF-alpha and TGF-beta) are important mediators which play a pleiotropic role in both inflammatory and hepatic regeneration processes. It has also been proposed that a major hepatectomy impairs the liver-related host defence mechanisms. The aim of this study was to evaluate the influence of minor (30%) vs major (80%) hepatectomy on cytokines, growth factors and acute-phase proteins both at the protein and mRNA levels in rat. For that purpose, rats were submitted to either 30% or 80% hepatectomy and sacrificed at intervals up to day 14 post-hepatectomy to collect liver and blood samples. Serum levels of IL-6 and acute-phase proteins (APPs) were determined after RNA extraction, cytokine and acute-phase proteins gene expression were evaluated using a quantitative RT-PCR method. The results demonstrate that liver mRNA levels for IL-6 were early unregulated after a 80% resection only, whereas liver mRNA levels for IL-1 slowly increased following 30 or 80% hepatectomy. For TNF-alpha, no significant changes were observed between groups. Growth factor expression differed according to the extent of hepatic resection. Moreover, plasma levels of alpha2-macroglobulin (alpha2M) and alpha1 acid glycoprotein (AGP), two major APPs which respond differently to combination of cytokines, were significantly lowered after a major resection whereas levels of serum IL-6 showed no significant changes between groups. Paradoxically, in the 80% hepatectomized group, alpha2M mRNA expression was strongly increased at 4 h and 6 h post-hepatectomy as compared with the 30% hepatectomized group. Taken together, these results suggest that, although an increased level of hepatic IL-6 expression was observed following a major resection, the liver's capacity to synthesize normal levels of APPs was impaired. Moreover, these specific changes of cytokine gene expression seen in the liver following major hepatectomy might reflect a preferential activation of the IL-6-dependent APPs., (Copyright 1997 Academic Press Limited.)

Pro-inflammatory cytokines are produced after systemic or local inflammation by a wide variety of cell types including monocytes, macrophages, Kupffer and endothelial cells. Previous studies have shown that IL-6 gene expression does not occur in liver from rats undergoing an acute phase response after turpentine injection or controls. These data do not rule out the possibility that delivery of a pathogen to the liver via the portal circulation could directly activate the Kupffer cells. Rats were injected either intravenously or intraperitoneally with LPS, or subcutaneously with turpentine oil. The changes in IL-1 beta, IL-6, and TNF mRNA levels in monocytes (collected from portal vein or caval cein), peritoneal macrophages and liver over a 3-hour period post-treatment were examined. The kinetics of LPS-vs turpentine-induced cytokine mRNAs in these various cell types were compared by quantitative reverse transcription and polymerase chain reaction (RT-PCR). Our data demonstrate that an intrahepatic expression of cytokines in the non parenchymal cells was induced by an LPS challenge but not by a turpentine-induced inflammation. This process could act as a paracrine mechanism in the acute-phase response and play a role in the modulation of hepatic regeneration.

The serum level of IL-6 and expression of IL-6 mRNA in hepatocytes from regenerating liver were investigated in the rat. The IL-6 level in the serum was not significantly different from that of a control group of rats submitted to an acute experimental inflammation. IL-6 mRNA expression did not occur in the liver of hepatectomized rats as judged from Northern blotting experiments using an IL-6 riboprobe. These results suggest that if IL-6 is implicated in hepatic regeneration, this cytokine is not produced by the regenerating liver and must be delivered exogenously to the liver to modulate hepatic regeneration.