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Sleeve gastrectomy (SG) is the most frequently performed bariatric procedure in the world. Our purpose was to evaluate the percentage of excess weight loss (%EWL), resolution of obesity-related comorbidities after SG, and identify predictive factors of weight loss failure. A prospective cohort study of adults who underwent SG during 2014 in 7 Belgian-French centers. Their demographic, preoperative, and postoperative data were prospectively collected and analyzed statistically. Overall, 529 patients underwent SG, with a mean preoperative weight and body mass index BMI) of 118.9 ± 19.9 kg and 42.9 ± 5.5 kg/m, respectively. Body mass index significantly decreased to 32.2 kg/m at 5 years ( < .001). The mean %EWL was 63.6% at 5 years. A significant reduction in dyslipidemia (28.0%-18.2%), obstructive sleep apnea (OSAS) (34.6%-25.1%), and arterial hypertension (HTN) (30.4%-21.5%) was observed after 5 years, but not for diabetes and gastroesophageal reflux disease (GERD). At multivariate analysis, age >50 years old, BMI >50 kg/m, and previous laparoscopic adjustable gastric banding (LAGB) remained independent predictors of weight loss failure. Five years after SG, weight loss was satisfactory; the reduction of comorbidities was significant for dyslipidemia, OSAS, and HTN, but not diabetes and GERD. Age >50 years old, BMI >50 kg/m, and previous LAGB were independent predictors of weight loss failure.

Fetuin-A, a plasma multifunctional protein known to play a role in insulin resistance, is usually presented as a liver secreted protein. However, fetuin-A adipose tissue production has been also described. Here, we evaluated fetuin-A production by the liver and the adipose tissue during metabolic dysfunction-associated fatty liver disease (MAFLD)-non-alcoholic steatohepatitis (NASH) development. Fetuin-A was evaluated by enzyme-linked immunosorbent assay (ELISA), polymerase chain reaction (PCR), Western blot, and immunofluorescence in male foz mice fed a normal diet (ND) or a high fat diet (HFD) at various timepoints and in MAFLD-NASH patients. Foz mice fed a short-term HFD developed liver steatosis, insulin resistance, and increased circulating levels of fetuin-A compared to ND-fed mice. In mice and patients with NASH, fetuin-A was located not only in healthy or steatotic hepatocytes but also in some macrophages forming lipogranulomas. In both mice and humans, a significant amount of fetuin-A was present in the adipose tissue compared to the liver. However, messenger ribonucleic acid levels and cell culture experiments indicate that fetuin-A is produced by the liver but not by the adipose tissue. In conclusion, fetuin-A is produced by steatotic hepatocytes at early timepoints in MAFLD and correlates with insulin resistance both in mice and humans. In NASH, fetuin-A also co-localizes with activated liver macrophages and could be interpreted as a signal released by damaged hepatocytes.

Malgré le faible échantillonnage, cet article décrit très bien les différents vécus de patients ayant subi une chirurgie bariatrique. Il souligne, pour l’avenir, l’implication grandissante du médecin généraliste dans ce type de chirurgie, tant au niveau de l’indication opératoire par le biais de la concertation multidisciplinaire qu’au niveau du suivi post-opératoire à court et long terme. [...]

OBJECTIVES: Postoperative complications after Laparoscopic sleeve gastrectomy (LSG) can dramatically compromise patient's outcome. The aim of this study is to analyze the per- and postoperative short-term outcomes after LSG and to assess predictive risk factors of complications. METHODS: The study group consisted of 790 patients (610 women and 180 men) who underwent LSG In 2014. All interventions were performed by 18 experienced surgeons members of the Club Coelio. Data about preoperative work-up, surgical techniques, 30-days postoperative morbidity and mortality were collected. Endpoints were perioperative morbidity and mortality and assessment of potential risk factors for complications. RESULTS: Mean age and body mass index were respectively 39 years and 41.5kg/m2. Ninety-one patients (11.5%) had previous bariatric surgery. Morbidity rate was 4.7% (37/790) including 16 leaks (2.0%) and 9 bleedings (1.1%) and no deaths. Risk factors for leak were: previous adjustable banding (p = .0051), with no difference between removal of the banding and LSG in 1 or 2 steps, and type of endostapler (p = .0129). CONCLUSIONS: Leakage after Sleeve was rare but still observed even in experienced hands. The leak rate is particularly high when LSG is performed after adjustable gastric banding removal.

AIMS: To compare the perioperative parameters and excess weight loss between patients operated by laporoscopic Roux-en-Y gastric bypass (LRYGB), as a primary operation or a revisional, for insufficient weight loss after vertical banded gastroplasty (VBG) or adjustable gastric banding (AGB). METHODS: A retrospective analysis of all patients who underwent a LRYGB was performed for the period 2004-2011. Demographics, preoperative body mass index (BMI), co-morbidities, operation time, conversion rate, perioperative complications, hospitalization period, and % of excess BMI loss (%EBMIL) were investigated and compared between groups. RESULTS: Three hundred forty-two laparoscopic gastric bypass operations were performed, 245 were primary, and 97 revisional. Median follow-up was 30 months (range 0-108 months). Mean BMI (kg/m2) before bypass was 45.2 for primary laparoscopic Roux-en-Y gastric bypass (pLRYGB) and 41.1 for revisional laparoscopic Roux-en-Y gastric bypass (rLRYGB). Median operative time and length of stay were longer for rLRYGB 157.5 versus 235 min (p < 0.001) and 6 versus 6.5 days (p = 0.05). Conversion to laparotomy was performed in eight patients, 0.4% of primary and 7.2% of revisional. Morbidity rate was 6.5% in pLRYGB versus 10% in rLRYGB (NS). There was one death in the primary group. Percentage of EBMIL was significantly lower in the revisional group at 12, 18, and 24 months of follow-up. CONCLUSIONS: Revisional and primary gastric bypass have no statistical differences in terms of morbidity. The % of excess BMI loss is lower after revisional gastric bypass during the first 2 years of follow-up. The trend of weight loss or weight regain was similar in both groups.

La chirurgie bariatrique est reconnue comme une modalité à part entière du traitement de l’obésité sévère mais aussi de ses comorbidités. De nombreux centres de chirurgie bariatrique encouragent, voire imposent à leurs patients, une perte de poids durant la période pré-opératoire. Le but de cet article est de faire le point sur cette question et de proposer une attitude pratique dans l’attente de données concluantes. L’analyse de la littérature actuelle ne permet pas de conclure de façon univoque concernant l’intérêt de la perte de poids pré-opératoire dans le cadre de la chirurgie bariatrique. Il n’y a donc actuellement pas d’argument suffisant pour considérer que la perte de poids est un prérequis systématique à la chirurgie bariatrique. Le seul bénéfice démontré est la réduction de la taille du foie. Il reste cependant à démontrer par des études prospectives randomisées que la réduction du volume hépatique engendrée par la perte de poids pré-opératoire est accompagnée d’une réduction des complications per- et postopératoires sans risque de dénutrition., [Should we encourage patients to lose weight before bariatric surgery?] Bariatric surgery is recognized as a modality in its own right for the treatment of severe obesity but also of its comorbidities. Many centers of bariatric surgery encourage or even impose on their patients a weight loss before surgery. The purpose of this paper is to review the rationale of this practice and to propose a practical attitude in the expectation of conclusive data. The analysis of the current literature does not make it possible to conclude unequivocally about the value of preoperative weight loss in the context of bariatric surgery. There is thus currently no sufficient argument to consider that weight loss is a systematic prerequisite for bariatric surgery. The only benefit demonstrated is the reduction in liver size. It remains however to be demonstrated by randomized prospective studies that the reduction in hepatic volume caused by preoperative weight loss is accompanied by a reduction in per- and postoperative complications without any risk of undernutrition.

La reconnaissance de la chirurgie bariatrique comme une modalité à part entière du traitement de l’obésité et de ses comorbidités a conduit à une nette augmentation du nombre d’intervention de ce type. Afin de garantir le succès et de minimiser les risques, il paraît essentiel de connaître les grands principes du suivi postopératoire de ces patients. En effet, la chirurgie bariatrique impose une modification du comportement alimentaire, expose le patient à certaines complications et induit des carences nutritionnelles. Leur nature est fonction du type de chirurgie, soit purement restrictive (sleeve gastrectomie), soit mixte, restrictive et malabsorptive (bypass gastrique). Alors que les complications chirurgicales sont le plus souvent précoces, les carences nutritionnelles sont plus souvent tardives. Le suivi devra être intensifié en cas de comorbidités associées afin d’adapter le traitement médicamenteux. La grossesse ne pourra être envisagée qu’après une stabilisation du poids et la correction des carences.

We present a rare case of jejunal obstruction due to the migration of a laparoscopic adjustable gastric band (LAGB) that occurred 10 years after surgery and was successfully treated by laparoscopy. This report is compliant with the SCARE guidelines.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become during the last few years the most frequent procedure in bariatric surgery. However, complications related to the gastric staple line can be even more serious. The incidence of gastric fistula after LSG varies from 1 to 7%. Its management can be very challenging and long. In case of chronic fistula and failure of the previous treatment, total gastrectomy or Roux-en-Y fistulo-jejunostomy (RYFJ) might be considered. RYFJ has been described very rarely as a salvage procedure of gastric leaks after LSG. METHODS: Between January 2015 and December 2015, we have performed a RYFJ in two patients, with chronic and persisting gastric fistulas, one after LSG and one after duodenal switch, respectively. In the two patients, the RYFJ procedure was attempted laparoscopically but in one case (patient after duodenal switch), conversion into laparotomy was necessary because of severe intra-abdominal inflammatory adhesions. In our video, we are presenting the case of this particular patient treated laparoscopically with a late and persisting leak 1 year after LSG. RESULTS: In this multimedia high-definition video, we described the steps of our technique of laparoscopic RYFJ. There was neither mortality nor severe postoperative complications. The fistula control after a minimum of 6 months follow-up was 100% for both of patients. CONCLUSIONS: RYFJ in our particular case was efficient. However, larger series and longer follow-up are needed to confirm the efficiency of the RYFJ as a salvage procedure.

Objective: Rare disease Background: Gastric duplication is a rare malformation mostly diagnosed during childhood. Symptoms in adults are atypical, rare, or may be completely absent. The diagnosis is suggested after a morphological and histological assessment. The treatment is a complete surgical resection. Case Report: We report on a case of a 28-year-old woman referred to our unit for a surgical assessment of a gastric duplication of the antropyloric area associated with paraduodenal and pancreatic extensions, diagnosed by several image tools and histological confirmation. She had undergone a total laparoscopic resection of the duplication without violation of the gastric lumen or any other splanchnic injury. The postoperative course was uneventful and the patient was discharged on postoperative day seven without any complains. Conclusions: The present report illustrates that complete resection of a distal gastric duplication is feasible by a laparoscopic minimal invasive procedure and therefore is considered to be a safe therapeutic modality. Our case is the first distal gastric duplication cyst with pancreatic and paraduodenal extension reported in the literature completely resected by laparoscopic approach.

BACKGROUND: Vertically banded gastroplasty or adjustable gastric banding often result in weight regain, complications, or side effects. Failed restrictive bariatric procedures can be converted in revisional laparoscopic Roux-en-Y gastric bypass (LRYGB). This study aimed to compare weight loss, evolution of comorbidities, and quality of life (QOL) between primary versus revisional LRYGB. METHODS: Between 2004 and 2012, 374 patients underwent LRYGB as primary or revisional surgery performed by a single surgeon. Patient data were retrospectively reviewed; questionnaires of QOL were sent to all patients. Outcomes were evaluated according to Bariatric Analysis and Reporting Outcome System (BAROS) taking into account excess body mass index loss (EBMIL), correction of comorbidities, improvement in QOL, and complications. RESULTS: Two hundred thirty-two patients (62%) responded to the questionnaire, 163 patients in the primary group and 69 in the revisional group. Median follow-up was 36 months (12-108). Median percentages of EBMIL were, respectively, 74% (26.8-126.8) and 50% (-31.6-124.2) in the primary and the revisional groups (p < 0.01). Median BAROS score reached 6.5 (-2-9) in the primary group, against 4.3 (-1.8-9) in the revisional group (p < 0.01). There were significantly less "fair" and more "excellent" scores in the primary group, considering initial BMI before gastroplasty. Arterial hypertension and sleep apnea syndrome resolved, respectively, in 51 and 56% in the primary group and only in 29 and 33% in the revisional group (p < 0.01). CONCLUSIONS: According to BAROS score, revisional LRYGB for failed restrictive procedures provided poorer results than primary LRYGB in terms of weight loss, resolution of comorbidities and QOL.

Splenectomy is the only potentially curative treatment for chronic immune thrombocytopenic purpura (ITP) in adults. However, one-third of the patients relapse without predictive factors identified. We evaluate the predictive value of the site of platelet sequestration on the response to splenectomy in patients with ITP. Eighty-two consecutive patients with ITP treated by splenectomy between 1992 and 2013 were retrospectively reviewed. Platelet sequestration site was studied by (111)Indium-oxinate-labeled platelets in 93% of patients. Response to splenectomy was defined at last follow-up as: complete response (CR) for platelet count (PC) ≥100 × 10(9)/L, response (R) for PC≥30 × 10(9)/L and <100 × 10(9)/L with absence of bleeding, no response (NR) for PC<30 × 10(3)/L or significant bleeding. Laparoscopic splenectomy was performed in 81 patients (conversion rate of 16%), and open approach in one patient. Median follow-up was 57 months (range, 1-235). Platelet sequestration study was performed in 93% of patients: 50 patients (61%) exhibited splenic sequestration, 9 (11%) hepatic sequestration and 14 patients (17%) mixed sequestration. CR was obtained in 72% of patients, R in 25% and NR in 4% (two with splenic sequestration, one with hepatic sequestration). Preoperative PC, age at diagnosis, hepatic sequestration and male gender were significant for predicting CR in univariate analysis, but only age (HR = 1.025 by one-year increase, 95% CI [1.004-1.047], p = 0.020) and pre-operative PC (HR = 0.112 for > 100 versus <=100, 95% CI [0.025-0.493], p = 0.004) were significant predictors of recurrence-free survival in multivariate analysis. Response to splenectomy was independent of the site of platelet sequestration in patients with ITP. Pre-operative platelet sequestration study in these patients cannot be recommended.

BACKGROUND: Optimal preoperative treatment before colorectal cancer metastases (CRCM) resection remains unclear. This study evaluated pathological responses (pR) in CRCM resected after chemotherapy alone or combined with angiogenesis or epidermal growth factor receptor (EGFR) inhibitors. METHODS: Pathological response was retrospectively evaluated on 264 resected metastases from 99 patients. The proportion of responding metastases after different preoperative treatments was reported and compared. Patient's progression-free survival (PFS) and overall survival (OS) were compared based on pR. RESULTS: The combination of anti-angiogenics with oxaliplatin-based chemotherapy resulted in more pR than when they were combined with irinotecan-based chemotherapy (80% vs 50%; P<0.001). Inversely, the combination of EGFR inhibitors with oxaliplatin-based chemotherapy seemed to induce fewer pR than when they were combined with irinotecan-based treatment (53% vs 72%; P=0.049). Overall survival at 5 years was improved for patients with a pR in all resected metastases compared with those who did not achieve a pR (68.5% vs 32.6%; P=0.023) and this response was the only factor predicting OS in a multivariate analysis. CONCLUSION: The chemotherapy partner combined with angiogenesis or EGFR inhibitors influenced pR in resected CRCM. In our exploratory analysis anti-angiogenic/oxaliplatin-based regimens and anti-EGFR/irinotecan-based regimens were associated with the highest pR. Prospective randomised trials should be performed to validate these observations.

Vertically banded gastroplasty or adjustable gastric banding often result in weight regain, complications, or side effects. Failed restrictive bariatric procedures can be converted in revisional laparoscopic Roux-en-Y gastric bypass (LRYGB). This study aimed to compare weight loss, evolution of comorbidities, and quality of life (QOL) between primary versus revisional LRYGB.

BACKGROUND: Open exploration and endoscopic sphincterotomy (ES) remain the preferred treatment of common bile duct stones (CBDS). The recent spread of laparoscopy has worsened the dilemna of choosing between surgical and endoscopic treatment of CBDS. The aim of this study was to critically evaluate the results of our preliminary experience with laparoscopic common bile duct exploration (CBDE) for CBDS. METHODS: Ninety-two consecutive patients were prospectively submitted to laparoscopic CBDE. Surgical strategy included an initial transcystic approach or laparoscopic choledochotomy. Failure of stone clearance was managed by conversion to open CBDE or by postoperative ES. Electrohydraulic lithotripsy and papillary balloon dilatation were selectively used. Stone clearance was assessed by choledochoscopy and control cholangiography. RESULTS: The overall laparoscopic stone clearance in this series was 84% (transcystic route 63% and choledochotomy 93%). Conversion to laparotomy was mandatory in 12% of the patients because of incomplete stone clearance and in 5% because of intraoperative complications. Postoperative ES was required in 4% of the patients, giving an overall surgical success rate of 96%. When indicated (small and limited number of stones located below the cysticocholedochal junction, with a dilated and patent cystic duct) the transcystic route had the lower success rate, the higher complication rate, and the shorter operative time and postoperative hospital stay. When indicated (accessible and dilated common bile duct over 7 mm), laparoscopic choledochotomy had the higher success rate, the lower complication rate, the longer operative time, and the longer postoperative hospital stay, which is related to associated external biliary drainage. The hospital mortality included two high-risk patients (2%) and the complications rate was 15%. CONCLUSIONS: Laparoscopic CBDE is safe in selected patients. A stratified intraoperative surgical strategy is mandatory in dec

A series of 100 consecutive patients with perforated peptic ulcer were prospectively evaluated in a multicenter study. The feasibility of the laparoscopic repair was evaluated. All patients had peritonitis, 20% were in septic shock, and 57% had delayed perforation. Conversion to laparotomy was necessary in eight patients. The morbidity rate was 9% and mortality rate 5%. The mean delay of postoperative gastric aspiration (mean 3.4 days) and resumed food intake (mean 4.4 days) as well as the mean postoperative hospital stay (mean 9.3 days) were comparable to conventional surgery, but postoperative comfort was subjectively increased by laparoscopy and noticed by all laparoscopic surgeons participating in this study. Laparoscopic repair of perforated peptic ulcer proves to be technically feasable and carries an acceptable morbidity and mortality rate, compared with conventional surgery.