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Gastric sleeve stenosis (GSS) is described in 1%-4% of patients.To evaluate the role of endoscopy in the management of stenosis after laparoscopic sleeve gastrectomy using a standardized approach according to the characteristic of stenosis.Retrospective, observational, single-center study on patients referred from several bariatric surgery departments to an endoscopic referral center.We enrolled 202 patients. All patients underwent endoscopy in a fluoroscopy setting, and a systematic classification of the type, site, and length of the GSS was performed. According to the characteristics of the stenosis, patients underwent pneumatic dilatation or placement of a self-expandable metal stent or a lumen-apposed metal stent. Failure of endoscopic treatment was considered an indication for redo surgery, whereas patients with partial or complete response were followed up for 2 years. In the event of a recurrence, a different endoscopic approach was used.We found inflammatory strictures in 4.5% of patients, pure narrowing in 11%, and functional stenosis in 84.5%. Stenosis was in the upper tract of the stomach in 53 patients, whereas medium and distal stenosis was detected in 138 and 11 patients, respectively, and short stenosis in 194 patients. A total of 126 patients underwent pneumatic dilatation, 8 self-expandable metal stent placement, 64 lumen-apposed metal stent positioning, and 36 combined therapy. The overall rate of endoscopy success was 69%.GSS should be considered to be a chronic disease, and the endoscopic approach seems to be the most successful treatment, with a prolonged positive outcome of 69%. Characteristics of the stenosis should guide the most suitable endoscopic approach. (Surg Obes Relat Dis 2022;X:XXX-XXX.) © 2022 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Les comorbidités psychiatriques peuvent freiner l’accès à la chirurgie bariatrique, voire constituer une contre-indication. Leur fréquence et leur impact sur l’évolution du poids demandent à être mieux connus. Nous avons analysé dans cette étude les caractéristiques anthropométriques, psychiatriques et diététiques pré- et à 1 an postopératoire de 68 patients obèses opérés de chirurgie bariatrique à l’hôpital de la Pitié-Salpêtrière (Centre spécialisé obésité francilien centre) évalués de façon multidisciplinaire lors d’un hôpital de jour dès le début de leur parcours bariatrique entre février 2017 et mars 2019. Au début du parcours bariatrique, la prévalence des troubles psychiatriques (TP) passés ou actuels est de 37 %, essentiellement à type de troubles de l’humeur. La prévalence des troubles des conduites alimentaires (TCA) est de 13 %, à type de binge eating disorder ; elle est significativement plus élevée chez les patients avec TP que chez ceux sans TP (12 vs 2 % ; p = 0,02). La perte de poids à 1 an post-opératoire est de 29 % dans les 2 groupes de patients (p = 0,96). Elle est plus importante après by-pass gastrique en Yqu’après sleeve (respectivement 33 et 26 % ; p = 0,001). À 1 an post-opératoire, aucun patient ne présente de TCA. Nos résultats soulignent la nécessité d’identifier, d’évaluer et de prendre en charge les comorbidités psychiatriques dès le début du parcours de soins bariatriques afin de guider au mieux la préparation pré-opératoire. Les patients avec TP passés ou actuels ont une perte de poids après sleeve ou by-pass gastrique satisfaisante.

Cholangiocarcinoma (CC) incidence is rising worldwide. Obesity and its related metabolic impairments are associated with primitive liver malignancies including CC. While bariatric surgery (BS) is associated with decreased risk of incident cancer, few data are available regarding CC incidence, presentation, and management issues after BS. We retrospectively reviewed collected data on 1911 consecutive patients undergoing BS from 2010 to 2019. We recorded three cases (0.16%) of CC during the postoperative follow-up. All cases underwent a Roux-en-Y gastric bypass (RYGB) for class III obesity with metabolic diseases (i.e., type 2 diabetes mellitus, hypertension, dyslipidemia, and obstructive sleep apnea) without any personal or familial history of biliary disease. The patients presented with an inaugural jaundice or pruritus at 8, 12, and 13 months after RYBG, which enabled the diagnosis of metastatic CCs in all cases. In such palliative setting without access to the pancreato-biliary system, biliary drainage was ensured by a percutaneous trans-hepatic biliary drain. Chemotherapy was initiated in two patients. All the patients died within a delay of 2, 11, and 17 months after the diagnosis, respectively. The incidence of post-BS CC appears low, but the prognosis is poor because of advanced stages at diagnosis. These cases illustrate the difficulty to make both on-time diagnosis and optimal management of CC especially in patients operated of RYGB with limited access to the excluded anatomy.

Background and objectives We previously showed in a 6-month randomized controlled trial that resistance training and protein supplementation after bariatric surgery (Roux-en-Y gastric bypass, RYGB) improved muscle strength without significant effect on weight loss and body composition changes. We performed a 5-year follow-up study in these subjects with the aim 1) to assess the long-term effect of this exercise training intervention and 2) to analyze associations between habitual physical activity (PA) and weight regain at 5 years. Methods Fifty-four out of 76 initial participants (follow-up rate of 71%) completed the 5-year follow-up examination (controls, n = 17; protein supplementation, n = 22; protein supplementation and resistance training, n = 15). We measured body weight and composition (DXA), lower-limb strength (leg-press one-repetition maximum) and habitual PA (Actigraph accelerometers and self-report). Weight regain at 5 years was considered low when Results Mean (SD) time elapse since RYGB was 5.7 (0.9) y. At 5 years, weight loss was 32.8 (10.1) kg, with a mean weight regain of 5.4 (SD 5.9) kg compared with the 12-month assessment. Moderate-to-vigorous PA (MVPA) assessed by accelerometry did not change significantly compared with pre-surgery values (+5.2 [SD 21.7] min/d, P = 0.059), and only 4 (8.2%) patients reported participation in resistance training. Muscle strength decreased over time (overall mean [SD]: -49.9 [53.5] kg, respectively, P Conclusions Early postoperative participation in a resistance training protocol after bariatric surgery was not associated with improved muscle strength after 5 years of follow-up; however, increasing physical activity of at least moderate intensity may promote weight maintenance after surgery. PA may therefore play an important role in the long-term management of patients with obesity after undergoing bariatric procedure.

To provide greater insight into bariatric surgery outcomes in aging patients, we compared changes in body weight, body composition, obesity-related comorbidities, and nutritional status between older and younger subjects. We analyzed data collected between January 2004 and December 2014 from our prospective bariatric cohort. Older patients (OP, ≥ 60 years at the time of surgery, n = 93; 66% Roux-en-Y gastric bypass, 34% sleeve gastrectomy) were compared with younger patients (YP

Background Endoscopy plays a pivotal role in the management of adverse events (AE) following bariatric surgery. Leaks, fistulae, and post-operative collection after sleeve gastrectomy (SG) may occur in up to 10% of cases. Objectives To evaluate the efficacy and safety of endoscopic internal drainage (EID) for the management of leak, fistula, and collection following SG. Setting Retrospective, observational, single center study on patients referred from several bariatric surgery departments to an endoscopic referral center. Methods EID was used as first-line treatment for the management of leaks, fistulae, and collections. Leaks and fistulae were treated with double pigtail stent (DPS) deployment in order to guarantee internal drainage and second intention cavity obliteration. Collections were treated with endoscropic ultrasound (EUS)–guided deployment of DPS or lumen apposing metal stents. Results A total of 617 patients (83.3% female; mean age, 43.1 yr) were enrolled in the study for leak (n = 300, 48.6%), fistula (n = 285, 46.2%), and collection (n = 32, 5.2%). Median follow-up was 19.5 months. Overall clinical success was 84.7% whereas 15.3% of cases required revisional surgery after EID failure. Clinical success according to type of AE was 89.5%, 78.5%, and 90% for leak, fistula, and collection, respectively. A total of 10 of 547 (1.8%) presented a recurrence during follow-up. A total of 28 (4.5%) AE related to the endoscopic treatment occurred. At univariate logistic regression predictors of failure were: fistula (OR 2.012), combined endoscopic approach (OR 2.319), need for emergency surgery (OR 1.755), and previous endoscopic treatment (OR 4.818). Conclusion Early EID for the management of leak, fistula, and post-operative collection after SG seems a safe and effective first-line approach with good long-term results.

International audience

International audience; OBJECTIVE: Physical activity and dietary regimens to optimize health outcomes after bariatric surgery are not well known. This study aimed to determine whether resistance training with dietary protein supplementation is effective in maintaining body composition and physical fitness after obesity surgery.METHODS: Seventy-six women with obesity undergoing Roux-en-Y gastric bypass were randomly assigned at the time of surgery to receive either usual care (controls [CON], n = 22), usual care and additional (whey) protein intake (PRO, n = 31), or usual care, additional protein intake, and supervised strength training for 18 weeks (PRO+EX, n = 23). The primary outcome was pre- to 6-month postsurgery change in lean body mass (by dual-energy x-ray absorptiometry). Secondary outcomes included changes in muscle strength (by one-repetition maximum testing).RESULTS: Loss over time in lean body mass did not differ between groups (CON: mean,-8.8 kg; 95% CI: -10.1 to -7.5 kg; PRO: mean, -8.2 kg; 95% CI: -9.3 to -7.1 kg; PRO+EX: mean, -7.7 kg; 95% CI: -9.0 to -6.5 kg; P = 0.899). The increase in relative lower-limb muscle strength was higher in the PRO+EX group (+0.6 [0.3 to 0.8]) versus +0.1 (-0.1 to 0.4) and +0.2 (0.0 to 0.4) kg/kg body mass in CON and PRO groups, respectively (P = 0.021).CONCLUSIONS: Loss in muscle strength observed after bariatric surgery can be overcome by resistance training with additional protein intake.

Anti-retroviral therapy (ART) dramatically reduced AIDS development, thus enabling patients to live as long as the general population. New challenges have emerged particularly cardiometabolic diseases and weight gain, with some HIV patients seeking bariatric surgery (BS). However, BS outcomes during HIV remain poorly described, with scarce data on ART pharmacokinetic post-BS. Describing sleeve gastrectomy (SG) results in HIV patients in terms of ART pharmacokinetic, HIV control, weight loss, and metabolic outcomes. Prospective study of HIV patients undergoing SG in a referral academic center, with at least 6 months follow-up. Clinical and biological parameters, HIV medical history, and ART pharmacokinetics were gathered before and post-SG. Seventeen patients (mean BMI = 44.2 ± 5.7 kg m−2) and major obesity-related diseases (47% type-2 diabetes, 64% obstructive sleep apnea, 70% hypertension) underwent SG during a mean 2 years of follow-up. They displayed an average of 20% reduction of initial BMI and improved body composition, similarly to obese non-HIV patients. SG improved metabolic status. All patients had undetectable viral load before BS. Upon HIV follow-up, 12 patients had undetectable viral load with correct ART kinetic parameters (3 and 6 months); 4 displayed detectable viral load along with significant decrease in raltegravir and atazanavir treatment exposure, leading to ART change with subsequent undetectable viral load; and 1 had persistent detectable viral load despite ART change. SG seems effective and safe in obese HIV patients. However, ART treatment should be monitored post-SG to control HIV infection. We suggest that some ART should be adapted before SG conjoints with infectious disease specialists.

Obesity-induced white adipose tissue (WAT) fibrosis is believed to accelerate WAT dysfunction. However, the cellular origin of WAT fibrosis remains unclear. Here, we show that adipocyte platelet-derived growth factor receptor-α-positive (PDGFRα+) progenitors adopt a fibrogenic phenotype in obese mice prone to visceral WAT fibrosis. More specifically, a subset of PDGFRα+ cells with high CD9 expression (CD9high) originates pro-fibrotic cells whereas their CD9low counterparts, committed to adipogenesis, are almost completely lost in the fibrotic WAT. PDGFRα pathway activation promotes a phenotypic shift toward PDGFRα+CD9high fibrogenic cells, driving pathological remodeling and altering WAT function in obesity. These findings translated to human obesity as the frequency of CD9high progenitors in omental WAT (oWAT) correlates with oWAT fibrosis level, insulin-resistance severity, and type 2 diabetes. Collectively, our data demonstrate that in addition to representing a WAT adipogenic niche, different PDGFRα+ cell subsets modulate obesity-induced WAT fibrogenesis and are associated with loss of metabolic fitness.

Exercise training optimizes cardiorespiratory fitness (CRF) after bariatric surgery, but the effect of spontaneous physical activity is not well known. This study aimed to objectively quantify changes in CRF and habitual physical activity 6 months after bariatric surgery and to examine whether change in CRF was related to change in physical activity. Secondary analyses were performed on data from women who underwent Roux-en-Y gastric bypass (RYGB) between 2010 and 2014. Measurements were performed before and 6 months after RYGB and included VO2peak (graded maximal exercise test on a cycle ergometer), habitual physical activity (Actigraph GT3x accelerometer worn during 7 days), and body composition (DXA absorptiometry). Changes after RYGB were analyzed using Wilcoxon signed-rank test. Relations between change in CRF and change in physical activity were analyzed with Spearman correlations adjusted on age and preoperative BMI. Forty-five women (median [P25–P75] age, 43.0 [38.0–51.0] year; BMI, 42.6 [40.0–45.5] kg/m2) were included. Mean (SD) weight loss 6 months after RYGB was − 27.5 (7.9) kg (P

International audience; BACKGROUND: One anastomosis gastric bypass (OAGB) is increasingly used in the treatment of morbid obesity. However, the efficacy and safety outcomes of this procedure remain debated. We report the results of a randomised trial (YOMEGA) comparing the outcomes of OAGB versus standard Roux-en-Y gastric bypass (RYGB). METHODS: This prospective, multicentre, randomised non-inferiority trial, was held in nine obesity centres in France. Patients were eligible for inclusion if their body-mass index (BMI) was 40 kg/m(2) or higher, or 35 kg/m(2) or higher with the presence of at least one comorbidity (type 2 diabetes, high blood pressure, obstructive sleep apnoea, dyslipidaemia, or arthritis), and were aged 18-65 years. Key exclusion criteria were a history of oesophagitis, Barrett's oesophagus, severe gastro-oesophageal reflux disease resistant to proton-pump inhibitors, and previous bariatric surgery. Participants were randomly assigned (1:1) to OAGB or RYGB, stratified by centre with blocks of variable size; the study was open-label, with no masking required. RYGB consisted of a 150 cm alimentary limb and a 50 cm biliary limb and OAGB of a single gastrojejunal anastomosis with a 200 cm biliopancreatic limb. The primary endpoint was percentage excess BMI loss at 2 years. The primary endpoint was assessed in the per-protocol population and safety was assessed in all randomised participants. This study is registered with ClinicalTrials.gov, number NCT02139813, and is now completed. FINDINGS: From May 13, 2014, to March 2, 2016, of 261 patients screened for eligibility, 253 (97%) were randomly assigned to OAGB (n=129) or RYGB (n=124). Five patients did not undergo their assigned surgery, and after undergoing their surgery 14 were excluded from the per-protocol analysis (seven due to pregnancy, two deaths, one withdrawal, and four revisions from OAGB to RYGB) In the per-protocol population (n=117 OAGB, n=117 RYGB), mean age was 43.5 years (SD 10.8), mean BMI was 43.9 kg/m(2) (SD 5.6), 176 (75%) of 234 participants were female, and 58 (27%) of 211 with available data had type 2 diabetes. After 2 years, mean percentage excess BMI loss was -87.9% (SD 23.6) in the OAGB group and -85.8% (SD 23.1) in the RYGB group, confirming non-inferiority of OAGB (mean difference -3.3%, 95% CI -9.1 to 2.6). 66 serious adverse events associated with surgery were reported (24 in the RYGB group vs 42 in the OAGB group; p=0.042), of which nine (21.4%) in the OAGB group were nutritional complications versus none in the RYGB group (p=0.0034). INTERPRETATION: OAGB is not inferior to RYGB regarding weight loss and metabolic improvement at 2 years. Higher incidences of diarrhoea, steatorrhoea, and nutritional adverse events were observed with a 200 cm biliopancreatic limb OAGB, suggesting a malabsorptive effect. FUNDING: French Ministry of Health.

Type 1 diabetes patients, although typically lean, experience an increased prevalence of obesity, and bariatric surgery is considered in severe cases. Bariatric surgery in such patients leads to significant weight loss and decreased insulin requirements; however, effects on glycemic control remain discussed. We assessed, in obese patients with type 1 diabetes, the effects of bariatric surgery upon body weight, body composition, and glycemic control, including the occurrence of hypoglycemic events. Thirteen obese patients with type 1 diabetes who underwent bariatric surgery (Roux-en-Y gastric bypass n = 6, sleeve gastrectomy n = 7) were matched with obese patients without diabetes and with type 2 diabetes patients during 12 months of follow-up. Outcomes included body weight, DXA-assessed body composition, HbA1c, and incidence of hypoglycemia. At 12 months, median surgery-induced weight loss was 27.9 % (21.1–33.3), 26.1 % (24.8–29.7), and 27.5 % (21.8–32.1) in patients with type 1 diabetes, type 2 diabetes, and without diabetes, respectively, with no significant differences across the groups. Similar findings were observed for body fat changes. At 12 months, median HbA1c decreased from 8.3 to 7.6 % in type 1 diabetes patients versus 8.0 to 5.9 % in type 2 diabetes patients (P = 0.04 between the groups). In type 1 diabetes patients, the number of reported minor hypoglycemia increased transiently only at 6 months. Two patients reported severe hypoglycemia (one episode each). Type 1 diabetes patients benefit from bariatric surgery in terms of weight loss and glycemic control. Close monitoring of insulin therapy appears warranted to prevent minor hypoglycemia in the first months post-surgery.

Adipose tissue contains a variety of immune cells, which vary in abundance and phenotype with obesity. The contribution of immune cell-derived factors to inflammatory, fibrotic and metabolic alterations in adipose tissue is not well established in human obesity. Human primary adipose tissue cells, including pre-adipocytes, endothelial cells and mature adipocytes, were used to investigate deregulation of cell- and pathway-specific gene profiles. Among factors known to alter adipose tissue biology, we focus on inflammatory (IL-1β and IL-17) and pro-fibrotic (TGF-β1) factors. rIL-1β and rIL-17 induced concordant pro-inflammatory transcriptional programs in pre-adipocytes and endothelial cells, with a markedly more potent effect of IL-1β than IL-17. None of these cytokines had significant effect on fibrogenesis-related gene expression, contrasting with rTGF-β1-induced up-regulation of extracellular matrix components and pro-fibrotic factors. In mature adipocytes, all three factors promoted down-regulation of genes functionally involved in lipid storage and release. IL-1β and IL-17 impacted adipocyte metabolic genes in relation with their respective pro-inflammatory capacity, while the effect of TGF-β1 occurred in face of an anti-inflammatory signature. These data revealed that IL-1β and IL-17 had virtually no effect on pro-fibrotic alterations but promote inflammation and metabolic dysfunction in human adipose tissue, with a prominent role for IL-1β.

Objective Non-alcoholic fatty liver disease (NAFLD) is a frequent complication of morbid obesity, but its severity varies greatly and thus there is a strong need to better define its natural history in these patients. Design Liver biopsies were systematically performed in 798 consecutive patients with severe obesity undergoing bariatric surgery. Histology was compared with clinical, biological, anthropometrical and body composition characteristics. Results Patients with presumably normal liver (n=179, 22%) were significantly younger at bariatric surgery than patients with NAFLD (37.0 vs 44.4 years, p Conclusions These results suggest that young adults are more prone to store fat in subcutaneous tissue and reach the threshold of bariatric surgery indication before their liver is damaged. A shift of fat storage from subcutaneous to visceral adipose tissue compartment is associated with liver damages. Liver might also be targeted by subcutaneous hypertrophic adipocytes in females since hypertrophic adipocytes are more exposed to lipolysis and to the production of inflammatory mediators.

Liver and white adipose tissue (WAT) develop inflammation and fibrosis.The aim of the study was to evaluate the bioclinical relevance of WAT fibrosis in morbid obesity and diabetes and the relationships with tissue stiffness measured using a novel device.Observational and longitudinal studies were conducted in a hospital nutrition department.Biopsies of liver and subcutaneous WAT (scWAT) and omental adipose tissue were collected from 404 obese bariatric surgery candidates, of whom 243 were clinically characterized before surgery and 3, 6, and 12 months after surgery. In 123 subjects, liver and scWAT stiffness was assessed noninvasively using vibration-controlled transient elastography (VCTE).Bariatric surgery was performed for some patients.Adipose tissue fibrosis and stiffness and their link to obesity phenotypes were measured.scWAT fibrosis was positively associated with liver fibrosis (fibrosis score ≥2) (ϱ= 0.14; P = .01). VCTE-evaluated liver and scWAT stiffness was positively correlated with immunohistochemistry-determined liver (ϱ= 0.46; P = .0009) and scWAT fibrosis (ϱ= 0.48; P = .0001). VCTE-evaluated scWAT stiffness measures negatively associated with dual-energy x-ray absorptiometry-evaluated body fat mass (R = -0.25; P = .009) and were correlated with metabolic variables. Diabetic subjects showed increased scWAT stiffness. Participants less responsive to gastric bypass were older and more frequently diabetic, and they had increased body mass index, serum IL-6, and scWAT and liver fibrosis. Subjects with no diabetes and normal liver had higher fat mass and lower tissue fibrosis and stiffness.scWAT stiffness was associated with tissue fibrosis, obesity, and diabetes-related traits. Noninvasive evaluation of scWAT stiffness might be useful in clinical practice.

Obesity-induced white adipose tissue (WAT) fibrosis is believed to accelerate WAT dysfunction. However, the cellular origin of WAT fibrosis remains unclear. Here, we show that adipocyte platelet-derived growth factor receptor-α-positive (PDGFRα

Sleeve gastrectomy (SG) is a safe and efficient procedure with comparable results between conventional and single-incision approach in selected patients. However, the critical point in both approaches is the retraction of the hypertrophic and fatty left lobe of the liver which increases technical difficulties and limit the exposure of the hiatus. Traditional liver retractors require an additional sub-xiphoid incision for insertion and cause post-operative pain as well as iatrogenic liver injuries. Various techniques have been described to allow adequate liver retraction through smaller incisions or fewer ports without compromising patient safety. However, some disadvantages of these methods are the need for incision of the liver ligament or diaphragmatic crura puncture rendering the device difficult to reposition.Two morbidly obese patients underwent a SG by conventional laparoscopy and by trans-umbilical single-incision using a novel minimal invasive internal liver retractor: the Versa Lifter Band®.This soft and flexible internal retractor was fully repositionable and adjustable intraoperatively. The time required to complete the liver retraction was 4 min 12 s in conventional surgery and 5 min 23 s in single-incision approach. Liver retraction was always satisfying resulting in limited intra-operative difficulties without the need of additional retractors/ports or conversion in both patients. No adverse outcomes occurred during the intra and post-operative periods without rise in aspartate aminotransferase and alanine-aminotransferase serum levels.In our preliminary experience, this internal liver retractor was easy to handle and provided an effective and safe retraction with good exposure of the surgical field and improved ergonomy in single incision as well as reduced port laparoscopic SG.

Extracellular matrix (ECM) in sc adipose tissue (scAT) undergoes pathological remodeling during obesity. However, its evolution during weight loss remains poorly explored. Objective: The objective of the investigation was to study the histological, transcriptomic, and physical characteristics of scAT ECM remodeling during the first year of bariatric surgery (BS)-induced weight loss and their relationships with metabolic and bioclinical improvements. Design, Setting, Patients, and Interventions: A total of 118 morbidly obese candidates for BS were recruited and followed up during 1 year after BS. Main Outcome Measures: scAT surgical biopsy and needle aspiration as well as scAT stiffness measurement were performed in three subgroups before and after BS. Fourteen nonobese, nondiabetic subjects served as controls. Results: Significantly increased picrosirius-red-stained collagen accumulation in scAT after BS was observed along with fat mass loss, despite metabolic and inflammatory improvements and undetectable changes of scAT stiffness. Collagen accumulation positively associated with M2-macrophages (CD163+ cells) before BS but negatively afterward. Expression levels of genes encoding ECM components (eg, COL3A1, COL6A1, COL6A2, ELN), cross-linking enzymes (eg, lysyl oxidase [LOX], LOXL4, transglutaminase), metalloproteinases, and their inhibitors were modified 1 year after BS. LOX expression and protein were significantly decreased and associated with decreased fat mass as well as other cross-linking enzymes. Although total collagen I and VI staining decreased 1 year after BS, we found increased degraded collagen I and III in scAT, suggesting increased degradation. Conclusions: After BS-induced weight loss and related metabolic improvements, scAT displays major collagen remodeling with an increased picrosirius-red staining that relates to increased collagen degradation and importantly decreased cross-linking. These features are in agreement with adequate ECM adaptation during fat mass loss - See more at: http://press.endocrine.org/doi/10.1210/jc.2015-3348#sthash.PLeUvzKd.dpuf

Anterior fixation via a gastro-gastric suture in laparoscopic adjustable gastric banding (LAGB) is commonly performed to prevent band-related complications. However, the necessity of this common technique has never been proven. Not fixing the band would be time sparing and would reduce adhesions on the stomach and probably make revisional surgery easier. This study was conceived as a 3-year randomised clinical trial to test the safety and efficacy of the non-fixation technique. From December 2006 to December 2007, 81 patients undergoing LAGB were randomly distributed into two groups: group A, with gastro-gastric sutures (n = 41) and group B, without gastro-gastric fixation (n = 40). The two groups were equivalent regarding initial body mass index (BMI), age and sex ratio. The main outcome was postoperative complications and secondary outcomes were operative time and weight loss expressed by the percentage of excess BMI loss (%EBMIL). All patients were prospectively followed up for 2 years. The mean preoperative BMI was 42.5 kg/m² (35-56). All patients were available for follow-up at 2 years. The mean overall preoperative time was 82 ± 20 min for the fixation group and 72 ± 20 min for the non-fixation group (p = 0.13). The mean hospital stay was 4.1 ± 1.5 days (no significant difference between the two groups). The 2-year %EBMIL was 35.9 for group A and 39.4 for group B (p = NS). The mean BMI at 2 years was 36.3 and 36.1, respectively, with no statistical difference. We observed three early band slippages in the non-fixation group and none in the fixation group. Three bands were removed during the second year of follow-up for causes other than band slippage (no significant difference between the two groups). This study was interrupted before a statistical significance could be reached, under the general agreement of all participating surgeons, because of the three unexpected early band slippages. For the patients who did not suffer from this complication, we did not observe any differences between the two groups in terms of late complications and weight loss. The operative time was shorter in the non-fixation group. This randomised clinical trial suggests that care should be taken when not fixating the LAGB because of the risk of early postoperative band slippage. We suggest that fixing the LAGB by gastro-gastric sutures should remain common practice.

Prosthetic reinforcement is the gold standard treatment for inguinal hernia and reduces the risk of recurrence. Yet up to one-third of patients complain of post-surgical pain due to irritation and inflammation caused by the mesh and the fixation materials. Of these patients, 3-4% will experience severe and disabling chronic pain. We performed a prospective multicenter clinical study of a self-adhering prosthesis, consisting of a lightweight polypropylene mesh (40 g/m²) coated on each side with synthetic glue, to evaluate early postoperative complications and patient outcomes.Between August 2008 and June 2010, 186 patients underwent hernia repair using the Lichtenstein technique and the self-adhering prosthesis. Primary endpoints were the frequency of disabling complications and quality of life (QoL) at 3-month follow-up. Pain, numbness, and groin discomfort were evaluated pre- and postoperatively (1 week, 1 and 3 months) using a visual analogue scale (VAS). Patients' pre- and postoperative QoL were measured using the SF12 questionnaire. Secondary endpoints were number of complications and recurrence rate, use of analgesic drugs, length of hospital stay, delay to return to normal activities, and patient satisfaction. The quality of the self-adhering mesh and its clinical utility were also evaluated by the participating surgeons.A total of 186 patients were enrolled and followed for at least 3 months after inguinal hernia repair. A total of 174 (95%) primary hernias and 12 (5%) recurrent hernias were treated. There were no intraoperative complications, no recurrences, and no repeat interventions performed during the study. The post-surgical complication rate was 4.5%. The mean delay to recover normal physical activity was 4 days. For the primary endpoint of pain, a VAS of zero was reported by 93/184 (50.5%) patients at 1 week, 130/171 (76.0%) patients at 1 month and 119/132 (90.2%) patients at 3 months' follow-up (P 0.0001). The postoperative SF12 scores showed a significant improvement in patient QoL following surgery (P 0.0001).Adhesix( ® ) self-adhering mesh for prosthetic reinforcement following inguinal hernia repair is atraumatic and associated with infrequent post-surgical complications or pain, a rapid recovery rate, and a high patient-reported QoL. A longer follow-up is underway to assess the frequency of post-surgical recurrence.

Early post-operative pain after inguinal hernia repair delays management in ambulatory setting. The type of mesh used for repair appears to influence their incidence. The aim of this randomized, prospective study using the alternation principle was to compare post-operative early pain and the quality of life of patients operated on for inguinal hernia depending on the type of mesh used and their impact on management in ambulatory setting. Fifty successive patients were included prospectively. Hernia repair was performed using the Lichtenstein procedure with two types of mesh, namely standard polypropylene 100 g/m2 (Prolene®) or light polypropylene (55 g/m2) with a natural beta-d-glucan coating (Glucamesh®). The main assessment criterion was post-operative pain evaluated twice daily by the patient for 7 days, using the visual analogue scale (VAS) and their use of analgesics. The secondary assessment criteria were the rate of unscheduled admissions the evening of the intervention and the hospital length of stay and the quality of life evaluated by the SF12 questionnaire at pre-operative stage and on days 7 and 30. The two groups were comparable. The operative durations were identical (38.8 ± 10.2 vs 48 ± 15.4 min). On the evening of the intervention before discharge, the pain was less intense in the Glucamesh® group (mean VAS score 21.6 ± 2.4 vs 31.7 ± 6.2, p = 0.02). On day 4, 20% of patients from the Glucamesh® group and none of the patients from the Prolene® group had a VAS score of 0 (p = 0.02). There were no unscheduled admissions in either group, but the hospital stay was significantly shorter in the Glucamesh® group compared with the Prolene® group (288 ± 35 vs 360 ± 48 min, p = 0.02). The post-operative quality of life evaluated by the SF12 questionnaire from day 7 to day 30 was the same in both groups (38 ± 4.8 vs 37 ± 5.2) and altered as at pre-operative stage compared with a control population (normal = 50). This randomized, prospective study showed that the use of a self-adhesive, light mesh, reducing the fixation sutures and coated with factors favouring tissue integration, such as the Glucamesh® prosthesis, significantly reduced early post-operative pain compared with conventional prostheses and could increase the percentage of patients likely to undergo an ambulatory hernia repair.

Roux-en-Y gastric bypass (GBP) and sleeve gastrectomy (SG) have increased dramatically, potentially increasing the prevalence of nutritional deficiencies. The aim of this study was to analyze the effects of food restriction during the first year after bariatric surgery (BS) on nutritional parameters. Twenty-two and 30 obese patients undergoing GBP and SG were prospectively followed at baseline and 3, 6, and 12 months after BS (N = 14 and N = 19 at T12). We evaluated food intake and nutrient adequacy (T0, T3, T12), as well as serum vitamin and mineral concentration (T0, T3, T6, T12). At baseline, GBP and SG patients had similar clinical characteristics, food intake, nutrient adequacy, and serum concentration. The drastic energy and food reduction led to very low probabilities of adequacy for nutrients similar in both models (T3, T12). Serum analysis demonstrated a continuous decrease in prealbumin during the follow-up, indicating mild protein depletion in 37 and 38 % of GBP patients and 57 and 52 % of SG patients, respectively, at T3 and T12. Conversely, despite the low probabilities of adequacy observed at T3 and T12, systematic multivitamin and mineral supplementation after GBP and SG prevented most nutritional deficiencies. GBP and SG have comparable effects in terms of energy and food restriction and subsequent risk of micronutrient and protein deficiencies in the first year post BS. Such results advocate for a cautious monitoring of protein intake after GPB and SG and a systematic multivitamin and mineral supplementation in the first year after SG.

Few data exist about the characteristics and management of enteric leaks after mini-gastric bypass (MGB).We aimed to describe the incidence, presentation, and surgical management of enteric leaks in patients who underwent laparoscopic MGB for morbid obesity.Private practice.An 8-year, 9-month retrospective chart review was performed on patients who had enteric leak requiring reoperation after MGB at a single institution.Thirty-five of 2321 patients were included. Ninety-seven percent had symptoms. Arterial hypertension and heavy smoking were predicting factors of leaks occurrence post-MGB (P.01). Enteric leak was diagnosed by systematic upper gastrointestinal series in 4 pts (11.4%) and by computed tomography with oral water soluble contrast in 4 of 31 pts (13%). In the other 27 patients, diagnosis of the leak was made intraoperatively. Eleven patients (32%) had leak arising from the gastric stapler line (type 1), 4 (11%) from the gastrojejunal anastomosis (type 2), and 20 (57%) from undetermined origin. The most common presentation was intra-abdominal abscess in type 1 and leaks of undetermined origin and generalized peritonitis in type 2. One third of the patients who underwent reoperation developed well-drained chronic fistula into the irrigation-drainage system, with complete healing in all patients without any further procedure. The mean hospital stay was 19 days with no mortality reported.Enteric leak leading to intra-abdominal sepsis post-MGB is rare (1.5%) An operative aggressive management based on clinical symptoms is the treatment of choice allowing no postoperative leak-related mortality and complete healing.

Obesity and bariatric surgery (BS) are increasing worldwide and can potentially lead to incidental diagnosis of benign gastric tumor including gastric leiomyoma (GL). When indicated, local tumor enucleation, completed through laparoscopic minimal-invasive approaches, has proven to be safe and effective especially when located near the esophagogastric junction (EGJ) with limited morbidity as compared to partial or total gastrectomies. Little is known regarding the most appropriate strategy concerning the management of GL regardless of the location in patients' candidate for BS.We present the case of a 67-year-old morbidly obese woman. She presented with an incidental 3-cm GL developed near the EGJ and antral histologic abnormalities mandating a gastric follow-up. Therefore, we performed both laparoscopic transgastric enucleation and sleeve gastrectomy simultaneously.After identification of the lesion, the gastrocolic ligament was divided and a gastrotomy was performed along the greater curvature to expose the tumor. Once the submucosal plan was identified, the lesion was enucleated from the submucosamuscle junction. After closure of the mucosal defect and ensuring the absence of gastric wall perforation, a conventional laparoscopic sleeve gastrectomy was performed. No adverse outcomes occurred during the post-operative period. The final pathologic diagnosis showed a completely resected and benign leiomyoma.Herein, we report the first laparoscopic transgastric enucleation of a GL localized close to the EGJ performed concomitant with a sleeve gastrectomy. This combined approach appeared feasible, safe, and do not compromise the access to the GI tract as well as potential future curative treatments on the gastric sleeve.

Adipocyte volume has been associated with insulin resistance and type 2 diabetes.Our purpose was to identify an adipocyte volume threshold linked with increased insulin resistance risk, and to examine its association with insulin resistance improvement after bariatric surgery.We investigated two cohorts of Caucasian women, candidates for bariatric surgery, from two institutional centers in France (age 42.0 ± 11.5 years; body mass index, 47.6 ± 6.9 kg/m(2)) and Germany (age 41.3 ± 11.2 years; body mass index, 49.5 ± 8.1 kg/m(2)). 38% of the subjects had gastric bypass surgery and were followed for 6 months after the intervention. We defined a group of subjects with type 2 diabetes or at risk of type 2 diabetes (DRD) and investigated the relations between adipocyte volume and this status before and after surgery.In both cohorts, subjects with DRD presented enlarged adipocytes (France, P = 3×10(-4); Germany, P =3×10(-10)) and we were able to determine thresholds in each cohort above which diabetes risk was potentially increased (France: 1003±42 pL, Germany: 798±32 pL). Subjects above those adipocyte thresholds were less prone to disappearance of the DRD status after bypass surgery (France, risk ratio = 2.1, P = .024; Germany, risk ratio = 1.3, P = .05).We show in two cohorts of morbidly obese subjects that a specific adipocyte volume threshold may predict an increased risk for obesity-associated type 2 diabetes. However, this threshold might be established for each specific investigation site. Having a high adipocyte size is associated with a lower improvement of insulin resistance after bypass surgery in both cohorts.

Introduction Les maladies de l’obesite, comme le diabete, sont associes a l’accumulation de tissu adipeux dans la region intra-abdominale. Les mecanismes moleculaires et cellulaires qui influencent l’obesite viscerale sont mal compris. Il y a un interet croissant dans la capacite des macrophages des tissus adipeux a controler l’inflammation vers une reponse pathologique favorisant le developpement du diabete. Interferon regulatory factor 5 (IRF5) est decrit comme un important regulateur de la polarisation des macrophages vers un phenotype pathologique (pro-inflammatoire). Son role est bien connu dans les pathologies auto-immunes comme l’arthrite rhumatoide ou le lupus. Cependant, les fonctions immuno-metaboliques de IRF5 sont encore meconnues. Nous emettons l’hypothese que l’alteration de l’activite de IRF5 va limiter la pathogenicite de l’obesite visceral et le developpement du diabete. Materiels et methodes Etude in vivo : Afin de decrire le role de IRF5 dans l’obesite viscerale et le developpement de l’insulinoresistance. Nous avons utilise deux modeles murins presentant une invalidation de IRF5 dans toutes les cellules (KO Total) et specifiquement dans les cellules myeloides (macrophages). Les souris ont ete soumises a un regime standard et riche en graisse (60 % de gras) pendant 12 semaines. Les souris ont ete ensuite caracterisees sur le plan metabolique, immunitaire et moleculaire. Etude humaine : Afin de transposer nos observations sur nos modeles murins, nous avons analyse l’expression de IRF5 dans le tissu adipeux visceral de sujets minces (n = 15), en surpoids (n = 15), obese (n = 14) et super obeses (n = 36). Nous avons pu ensuite determiner les relations entre l’expression de IRF5 avec les parametres anthropometriques et metaboliques de ces differents groupes de sujets. Resultats Dans cette etude nous demontrons que l’invalidation de IRF5 limite l’accumulation du tissu adipeux intra-abdominal et favorise l’accumulation dans les regions plus superficielles comme la region inguinale. Cette modification a pour effet de proteger les souris contre l’insulino-resistance et l’intolerance au glucose. De maniere surprenante, le tissu adipeux intra-abdominal des souris invalidees pour IRF5 est caracterise par une augmentation de nombre de macrophages et par l’accumulation des depots de collagene. Le changement de polarisation des macrophages entraine un remodelage adaptatif du tissu adipeux qui permet de le maintenir dans un etat sain. Les fonctions pathologiques de IRF5 ont egalement ete observees dans nos populations humaines ou l’expression de IRF5 est fortement associee a l’obesite viscerale et a l’insulinoresistance peripherique. Discussion Nos resultats demontrent pour la premiere fois une fonction metabolique deletere de IRF5 dans le l’obesite viscerale et le developpement du diabete. IRF5 pourrait etre utilise a des fins therapeutiques (inhibition de son activite) et a des fins diagnostics permettant une meilleure stratification du statut inflammatoire des patients diabetiques et proposer un traitement plus adaptes (immunotherapie). Declaration d’interet Les auteurs declarent ne pas avoir d’interet direct ou indirect (financier ou en nature) avec un organisme prive, industriel ou commercial en relation avec le sujet presente.

To present two cases of papillary carcinoma of the thyroglossal duct cyst (TDC) and to report their management.Two patients, a 47-year-old woman and a 60-year-old man, were operated in 2006 and 2008 in the Department of Digestive and Metabolic Surgery of the "Jean Verdier" Hospital.The diagnosis of papillary carcinoma was established after the pathological examination carried out on the thyroglossal duct cyst, after its complete surgical excision. A total thyroidectomy followed by a treatment by radioactive iodine and a substitutive hormonal therapy were carried out in the second time for one of the two patients. For the other patient, a total thyroidectomy followed by a substitute hormonal therapy, were achieved. The evolution was favorable, with a follow-up of four years for the first patient and two years for the second one.Total thyroidectomy after the complete excision of the cyst is currently the recommended treatment for the papillary carcinoma of the TDC. It was shown that a latent thyroid cancer could develop even 15 years after the initial excision of the thyroglossal cyst. The treatment is curative in 95% of the cases.Current treatment of papillary carcinoma of the thyroglossal duct cyst is well codified, allowing an excellent prognostic.

Background Seroma formation frequently occurs in patients who have undergone axillary lymphadenectomy. The aim of the study was to evaluate the effect of fibrin glue in the prevention of seroma formation after axillary lymphadenectomy. Materials and Methods Hundred fifty-nine breast cancer patients about to undergo quadrantectomy or mastectomy plus axillary lymphadenectomy were enrolled in the study and randomized into two groups. Fibrin glue spray applied to the axillary fossa plus placement of closed suction drainage were used in 80 patients (group A); placement of closed suction drainage was only used in 79 patients (group B). Results Group A patients showed a slight advantage with regard to the mean duration of axillary drainage placement (4.5 ± 1.3 days in group A vs. 5.1 ± 1.6 days in group B) and number of seroma aspirations (6.3 ± 1.1 in group A vs. 6.7 ± 1.2 in group B). No statistically significant differences were observed between the two groups of patients regarding the mean volume of total axillary drainage and of total seroma volume. Conclusions The use of fibrin glue does not prevent seroma formation and does not reduce seroma magnitude and duration. The costs of the product involved do not justify its routine use in patients undergoing axillary dissection. J. Surg. Oncol. 2010; 101:600–603. © 2010 Wiley-Liss, Inc.

Natural orifice translumenal endoscopic surgery (NOTES) is a major conceptual change in the field of modern surgery. However, corresponding technological refinements are not yet available to fill the gap separating the current laparoscopy from the NOTES of the future. Meanwhile, "hybrid" NOTES techniques, including single-port procedures, have been increasingly reported. This report describes a technique of single-incision laparoscopic appendectomy (SILA) for selected patients with acute appendicitis.Patients with noncomplicated acute appendicitis, excluding those with abscess, perforation, peritonitis, previous surgery, or obesity, underwent SILA. The procedure was performed using a single 15-mm-diameter umbilical incision with two 5-mm-diameter port sites.The study enrolled 36 women and 19 men with a mean age of 28 years (range, 18-78 years). The procedure was achieved for 41 patients (74.5%). The mean operative time was 39 min (range, 14-111 min). There was no mortality. The postoperative complication rate was 5.4% (3 complications in 3 patients), and the median hospital stay was 39 h (range, 8-240 h).The SILA technique is safe and feasible for selected patients with noncomplicated acute appendicitis. Compared with other transumbilical techniques of appendectomy, SILA has the advantages of feasibility without endoscopic skills and an acceptable operative time. Technical refinements and accomplished learning probably will enable its wider use for more patients with acute appendicitis.

IntroductionA retained surgical sponge in the abdomen is uncommon although it is likely that this finding is underreported in the medical literature. The intravisceral migration of retained surgical gauze is even rarer, as demonstrated by the very few cases reported.Case presentationThree years after undergoing anterior resection of the rectum, a 75-year-old man presented with symptoms of small bowel obstruction. Plain abdominal radiography and CT showed a radio-opaque marker; a foreign body was suspected, probably a piece of retained surgical gauze. An ileotomy of about 5 cm. was performed to confirm this diagnosis and remove the gauze.ConclusionAlthough rare, retained gauze in the abdomen is a complication of surgery. The authors consider that this event may be more frequent than it appears from reports in the literature, probably because of its medico-legal implications. If all such cases were reported, it would be possible to estimate their exact number, classify the occurrence as a possible surgical complication and thus modify its medico-forensic consequences.

Objectif Les jonctions serrees de l’epithelium digestif regulent la permeabilite paracellulaire intestinale (PPI). Chez les rongeurs, une PPI augmentee est associee a l’alteration du metabolisme, mais ceci reste peu documente chez l’Homme. Notre objectif a ete d’evaluer la PPI chez les sujets obeses (Ob) et obeses diabetiques (ObD) Materiels et methodes La PPI in vivo a ete evaluee par le ratio d’excretion urinaire du lactitol/mannitol (L/M) chez 25 Ob et 15 ObD, la Zonuline serique (bio-marqueur de l’etat de la barriere) et la calprotectine fecale (bio-marqueur de l’inflammation intestinale) en ELISA. Des dechets chirurgicaux de jejunum de 31 Ob et 17 ObD, obtenus pendant le bypass, ont permis de mesurer ex vivo la permeabilite aux FITC-dextran en chambre de Ussing. Resultats Les L/M etaient comparables entre Ob et ObD (1,2 % ± 2,1 ; 2,1 % ± 2 ; p = 0,80) indiquant l’absence d’augmentation de la PPI aux petites molecules. La Zonuline serique des ObD (20 ng/ml ± 3) etait semblable a celle des Ob (50 ng/ml ± 30) suggerant que le diabete n’aggrave pas la PPI. La PPI aux differentes molecules mesuree ex vivo etait comparable entre Ob et ObD, pour les molecules de 0,4 kDa (p = 0,83), 4 kDa (p = 0,76), ou 10 kDa (p = 0,95). La calprotectine fecale etait egalement comparable et restait sous le seuil de normalite (100 μg/g) (NS), indiquant l’absence de inflammation intestinale chez Ob et ObD. Les valeurs de PPI les plus elevees etaient retrouvees des sujets de meilleur statut metabolique (HOMA IR, IMC, HDL) et moins inflammes (leucocytose, CRPus) (p Conclusion Le diabete de type-2 ne modifierait pas la PPI aux petites molecules dans l’obesite morbide. L’inflammation intestinale serait absente dans les deux groupes. La comorbidite diabetique ne serait pas aggravante pour la PPI chez l’Homme. Il reste a etablir la PPI aux plus grosses molecules, bacteriennes par exemple.