Long-term complications after gastric bypass and sleeve gastrectomy: What information to give to patients and practitioners, and why?

Bariatric surgery is now recognized as the most effective treatment of morbid obesity, leading to durable weight loss and resolution of associated co-morbidities. Roux-en-Y gastric bypass and sleeve gastrectomy are the two most widely used operations today. However, potentially serious medical, surgical, and/or psychiatric complications can occur that raise questions regarding the benefits of this type of surgery. These complications can lead to surgical re-operations, iterative hospitalizations, severe nutritional deficiencies and psychological disorders. Indeed, death from suicide is said to be three times higher than in non-operated obese patients. These results are of concern, all the more because of the high prevalence of patients lost to follow-up (for various and multifactorial reasons) after bariatric surgery. However, better knowledge of post-surgical sequelae could improve the information provided to patients, the preoperative evaluation of the benefit/risk ratio, and, for patients undergoing surgery, the completeness and quality of follow-up as well as the detection and management of complications. The development of new strategies for postoperative follow-up such as telemedicine but also the mobilization of all the actors along the healthcare pathway can make inroads and warrant further study.

Bariatric revisional surgery: What are the challenges for the patient and the practitioner?

Bariatric revisional surgery represents an important new issue for obese patients because of the considerable rate of failure and complications following bariatric surgery. As the frequency of bariatric procedures increases, so too does the incidence of revisional surgery, which has become becoming increasingly important. The surgeon must know the indications and the results of the various revisional procedures in order to best guide the therapeutic decision. The current challenge is to correctly select the patients for revisional surgery and to choose the appropriate procedure in each case. Multidisciplinary management is essential to patient re-assessment and to prepare the patient for a re- intervention. The objective of this update, based on data from all the most recent studies concerning revisional surgery, is to guide the surgeon in the choice of the revisional procedure, depending on patient characteristics, co-morbidities, the previously performed procedure, the type of failure or complication observed, but also on the surgeon's own habits and the center's expertise. The collected results show that revisional surgery is difficult, with higher complication rates and weight-loss results that are often lower than those of first-intent surgery. For these reasons, patient selection must be rigorous and multidisciplinary and the management in expert centers of these difficult situations must be encouraged.

[Early restrictive feeding disorders: Quantitative assessment of parent/infant feeding interactions]. / Troubles du comportement alimentaire restrictif du nourrisson et du jeune enfant : évaluation quantitative des interactions parent/nourrisson pendant le repas.

INTRODUCTION: Interest in the study of early feeding disorders (FD) has steadily increased during recent decades. During this period, research described the importance of the transactional relationships and the complex interplay between caregiver and child over time. On the basis of the previous studies, our study tried to explore the associations between the characteristics of the parents and the temperamental characteristics of the infants with early FD. GOALS: A first aim of the present study was to show if parental perception of child temperament (including ability for arousal self-regulation) and parental characteristics (emotional and eating attitudes) are associated with early FD. A second aim was to identify emotional/behavioral difficulties in children with early FD by comparing children with a normal development and children with a diagnosed FD, and to investigate whether there are any correlations between parental emotional and feeding characteristics and a child's eating and emotional-behavioral development. A final aim was to explore if feeding conflict is bound to both infant ability for arousal self-regulatation and caregiver emotional status during meals. METHOD: Participants: 58 clinical dyads (children aged 1-36 months) and 60 in the control group participated in the study. The sample of 58 infants and young children and their parents was recruited in a pediatric hospital. They were compared to healthy children recruited in several nurseries. PROCEDURE: all parent-child pairs in the clinical sample were observed in a 20-minute video-recording during a meal using the procedure of the Chatoor Feeding Scale. After the videotaping, parents completed a battery of self-report questionnaires assessing their child's and their own psychological symptom status. MEASURES: Child's malnutrition assessment was based on the Waterlow criteria. The Child Behavior Checklist (CBCL 1½-5) was used to assess a child's emotional/behavioral functioning. The Infant Behavior Questionnaire-Revised (IBQ-R), a widely used parent-report measure of infant temperament, was used to identify the structure of infant temperament. The Eating Attitude Test-40, a self-report symptom inventory, was used to identify concerns with eating and weight in the adult population. The Chatoor Feeding Scale was used to assess mother-child feeding interactions during a meal based on the analysis of the videotaped feeding session. RESULTS: Analyses revealed that children with FD did not have a difficult temperament, especially no disability for arousal of self-regulatation, but their emotional-behavioral functioning is characterized by internalizing problems. Analyses of the EAT-40 showed that mothers of the children diagnosed with FD had significantly higher scores than mothers of the control sample; it means these mothers showed more dysfunctional eating attitudes. In addition, meals were characterized by negative effects in parents in the clinical group. When compared to the control sample, the feeding interactions between children with FD and their parents were characterized by low dyadic reciprocity, high maternal non-contingency, great interactional conflict and struggles with food. However, no significant correlation emerged either between the severity of malnutrition in infants or the conflict during feeding. CONCLUSION: Our study confirms the relations established in previous research. Finally, future longitudinal studies are needed to further clarify and investigate others factors that may be involved in early feeding disorders.

[Feeding disorders in infants and toddlers: At-risk situations and predisposing factors]. / Troubles du comportement alimentaire restrictifs du nourrisson et du jeune enfant : situations à risque et facteurs favorisants.

Feeding disorders and food refusal can be found in 25% of infants, with a minority of them having an organic explanation. Failure to thrive and/or severe malnutrition are found in 3-5% of infants in this population. The objective of this study was to analyze the risk factors of feeding disorders in infants and children less than 3 years of age. This study was conducted from January 2011 to December 2014 and included 103 children, 57 with feeding and/or eating disorders and 46 healthy children considered to be normal eaters. Parents participated in a structured interview and completed a data sheet to record the mode of delivery, neonatal status, medical history, milk feeding, and medical treatment. Statistical analysis indicated that cesarean delivery, prematurity, neonatal diseases, history of eating disorders in the family, consumption of protein hydrolysates, and treatment with proton pump inhibitors were highly significant risk factors in children with eating disorders. In the present study, we showed that several prenatal and postnatal conditions or interventions were associated with the development of eating disorders in young children. Recommendations for future studies include identifying environmental risk factors and implementing prevention programs focused on family, caregivers, as well as healthcare professionals. The objective is to allow physicians to efficiently sort out the wide variety of conditions, categorize them for therapy, and when necessary refer patients to specialists in the field.

[Toxicological study of emissions resulting from a diesel and a gazoline engine using an organotypic culture of lung slice]. / Etude toxicologique des gaz d'échappement issus de moteurs diesel et essence sur une culture organotypique de tissu pulmonaire.

INTRODUCTION: Many studies were carried out in vivo and/or in vitro for better understanding toxic effects of exhausts or particles emitted by Diesel vehicles. Few studies were interested in Gazoline engines when progress of metrology made it possible to highlight the presence of small particles with a strong capacity of penetration within pulmonary tissue. The aim of this study is to compare the toxic impact of the emissions of Diesel and Gasoline engines of recent technology. MATERIALS AND METHODS: Biological material was constituted by an organotypic rat lung precision slice. It was exposed to a continuous flow exhausts thanks to a preparation and dilutions system of these emissions placed on the line of exhaust. A measurement of the biological markers involved in the process of the lung tissue reaction to the air-contaminants was carried out. RESULTS: With Diesel exhausts, the results showed a stability of the rate of ATP and an increase in enzymatic activities of the antioxydant system (GPx and catalase). Gazoline emissions, as for them, were responsible for a cytotoxic attack of the pulmonary tissue defined by a reduction in the rate of ATP as well as a deterioration of the system of detoxication with reduction in the antioxydant enzymatic activities. CONCLUSION: These results show that toxicological profiles obtained with this system of exposure depends on the engine technology used, highlighting thus the specific response of the model in relation with the type of atmospheres which it is exposed.

Biphasic culture of rat lung slices for pharmacotoxicological evaluation of complex atmospheres.

The relevance to the in vivo situation of in vitro toxicity studies of complex atmospheres has frequently been limited by the procedures used for the exposure of the biological samples. We have evaluated from on-road measurements the size distribution pattern and the subsequent respiratory tract deposition rates of particulate matter from urban atmospheric aerosols, which are in the range of 110 and 3 pg/cm2 per min for tracheobronchial and alveolar areas, respectively. Continuous flow-through rotating chambers and a specific design for exhaust sampling and dilution with controlled adjustment of pO2 and pCO2 to 20% and 5%, respectively, have been developed to expose biphasic air/liquid organotypic cultures of rat lung slices to continuous flows of diluted exhausts from diesel engines with preservation of the physicochemical properties of the exhaust. The size distribution of the particulate matter and the bioavailability of pollutants were preserved, thus allowing us to closely mimic in vitro the in vivo atmosphere/tissue interactions that occur mainly through diffusion mechanisms. The toxicity response profile has been assessed in terms of tissue viability, oxidative stress, DNA injury, and the early phase of inflammatory reaction. Exhaust filtration, addition to fuel of rapeseed methyl ester, and preincubation of lung tissue with soy isoflavones modulated the toxicity response profile of exhausts. The importance of preserving both particulate matter size distribution and adsorbed pollutant bioavailability, which could not be ascertained using more classical in vitro approaches, is discussed and should be considered a prerequisite for further developments of in vitro studies to modelize in vivo inhalation of complex atmospheres.

Isoflavones protect against diesel engine exhaust injury in organotypic culture of lung tissue.

The wide range of potential health beneficial effects of isoflavones, including a chemoprentive action, have prompted us to study the potential benefits of genistein and daidzein in an experimental model of environmental pollution impact on lung tissue. A diesel engine placed was used to generate reproducible emissions including both gaseous and particulate matters that are commonly found in urban atmospheres. Isoflavones were added to culture medium of rat lung slices 2 h prior to their exposure to pollutants for 3 h. Intracellular ATP and GSH levels, TNFα production, nucleosome assay and TUNEL labeling were monitored. Isoflavones showed almost total in vitro protection against inflammatory and pro-apoptotic responses in lung slices. Isoflavones 0.3 and 1 µmol/l protected against exhaust induced GSH depletion. Isoflavones 0.3 µmol/l appeared to exert the most beneficial effects. In conclusion, this study points out the potential interest of soy isoflavones consumption in polluted areas. Further studies should be undertaken to verify that similar effects could be obtained after in vivo administration of isoflavones.

Toxicity of diesel engine exhausts in an in vitro model of lung slices in biphasic organotypic culture: induction of a proinflammatory and apoptotic response.

Precision-cut rat lung slices in organotypic culture placed in a biphasic air/liquid system were used for this study. This model allowed pathological as well as cellular and molecular biology investigations to be carried out. Slices were exposed to a continuous flow of diluted diesel exhaust, with a pO2 adjusted to 20% to avoid hypoxia-induced effects. The exposure system allowed five exhaust concentrations from the same diesel engine to be studied concomitantly, and also allowed the impact of removing the particulate matter using a filter cap on the exposure vials to be evaluated. Lung slices were exposed for 3 or 6 h to whole or filtered diesel exhaust. DNA integrity was characterized by two different techniques: (1) an ELISA for the determination of nucleosomes, and (2) the histochemical TUNEL method. By the TUNEL method, apoptotic cells were detected after a 6-h exposure followed by an incubation period of 18 h in a controlled atmosphere comprising 5% CO2/95% O2. Under these conditions, apoptotic nuclei were more frequent in slices exposed to diesel exhaust than in control slices. Cytokine production (tumor necrosis factor alpha, interleukin-1beta) in the culture medium was measured using an ELISA technique. After a 3-h exposure only TNF-alpha was detected and increased in the culture medium of lung slices exposed to diesel exhaust. Under the same conditions, nucleosome levels in the slices increases in a dose-dependent way. In conclusion, whole diesel exhaust induced an inflammatory response and DNA alterations which were reduced by filtration, thus indicating the important role of the particulate matter in diesel exhaust.

Synthesis of interleukin 1beta and interleukin 6 by stimulated rat peritoneal macrophages: modulation by glutamine.

Synthesis and secretion of IL-1beta and IL-6 were compared in LPS-stimulated rat peritoneal macrophages, and the effect of glutamine studied. LPS induced a parallel increase in mRNA and synthesis of IL-1beta and IL-6. IL-1beta accumulated mainly in the cytosol and IL-6 in the culture medium. Glutamine addition increased the synthesis of both cytokines, but the overall production (intra-+extracellular) of IL-1beta increased two-fold, although that of IL-6 increased only 1.3-fold. The influence of glutamine is discussed.

Glutamine accelerates interleukin-6 production by rat peritoneal macrophages in culture.

The effect of glutamine on the production of interleukin-6 (IL-6) was studied in rat peritoneal macrophages in culture. A maximal production of IL-6 was measured at 4 h in lipopolysaccharide (LPS)-stimulated macrophages, and addition of glutamine (5 mM) anticipated this increase by 1 h without any increase in the IL-6 mRNA level. The effect of glutamine required the presence of LPS. Thus, glutamine accelerates IL-6 production from the pre-existing mRNA. The effect of glutamine was not mediated by cell swelling since culture of macrophages in hypoosmotic condition decreased the production of IL-6 in the culture medium with a corresponding decrease in the IL-6 mRNA level.