Ectopic adrenal cortex associated with epididymal malformation in adult: A clinical case report.

To report a case of unusual ectopic adrenal cortex in adult. A 35-year-old male consulted for vasectomy. During the procedure, a small right epididymal cyst was incidentally found. The ductus deferens was not identified. It was decided to achieve the treatment with a surgical exploration and the cyst was excised from the epididymis. The pathological analysis showed a nodule with microscopic adrenocortical tissue. Ectopic adrenal cortex is normally seen in children. Epididymal localization in adults is a rare finding. Ectopic adrenal cortex is a benign lesion and no further investigation is mandatory.

Selective effects of PPARgamma agonists and antagonists on human pre-adipocyte differentiation.

AIM: The insulin sensitizer rosiglitazone (RTZ) acts by activating peroxisome proliferator and activated receptor gamma (PPAR gamma), an effect accompanied in vivo in humans by an increase in fat storage. We hypothesized that this effect concerns PPARgamma(1) and PPARgamma(2) differently and is dependant on the origin of the adipose cells (subcutaneous or visceral). To this aim, the effect of RTZ, the PPARgamma antagonist GW9662 and lentiviral vectors expressing interfering RNA were evaluated on human pre-adipocyte models. METHODS: Two models were investigated: the human pre-adipose cell line Chub-S7 and primary pre-adipocytes derived from subcutaneous and visceral biopsies of adipose tissue (AT) obtained from obese patients. Cells were used to perform oil-red O staining, gene expression measurements and lentiviral infections. RESULTS: In both models, RTZ was found to stimulate the differentiation of pre-adipocytes into mature cells. This was accompanied by significant increases in both the PPARgamma(1) and PPARgamma(2) gene expression, with a relatively stronger stimulation of PPARgamma(2). In contrast, RTZ failed to stimulate differentiation processes when cells were incubated in the presence of GW9662. This effect was similar to the effect observed using interfering RNA against PPARgamma(2). It was accompanied by an abrogation of the RTZ-induced PPARgamma(2) gene expression, whereas the level of PPARgamma(1) was not affected. CONCLUSIONS: Both the GW9662 treatment and interfering RNA against PPARgamma(2) are able to abrogate RTZ-induced differentiation without a significant change of PPARgamma(1) gene expression. These results are consistent with previous results obtained in animal models and suggest that in humans PPARgamma(2) may also be the key isoform involved in fat storage.

A new type of internal hernia after laparoscopic Roux-en-Y gastric bypass.

Roux-en-Y gastric bypass (RYGBP) is currently the most common bariatric procedure. One of its late complications is the development of internal hernia, which can lead to acute intestinal obstruction or recurrent colicky abdominal pain. The aim of this paper is to present a new, unusual, and so far not reported type of internal hernia. A common computerized database is maintained for all patients undergoing bariatric surgery in our departments. The charts of patients with the diagnosis of internal hernia were reviewed. Three patients were identified who developed acute intestinal obstruction due to an internal hernia located between the jejunojejunostomy and the end of the biliopancreatic limb, directly between two jejunal limbs with no mesentery involved. Another seven patients with intermittent colicky abdominal pain, re-explored for the suspicion of internal hernia, were found to also have an open window of the same location apart from a hernia at one of the typical hernia sites. Since this gap is systematically closed during RYGBP, no other patient has been observed with this problem. Even very small defects can lead to the development of internal hernias after RYGBP. Patients with suggestive symptoms must be explored. Closure of the jejunojejunal defect with nonabsorbable sutures prevents the development of an internal hernia between the jejunal loops at the jejunojejunostomy.

Internal hernia after laparoscopic Roux-en-Y gastric bypass for morbid obesity: a continuous challenge in bariatric surgery.

BACKGROUND: Roux-en-Y gastric bypass (RYGBP) has long been associated with the possible development of internal hernias, with a reported incidence of 1-5%. Because it induces fewer adhesions than laparotomy, the laparoscopic approach to this operation appears to increase the rate of this complication, which can present dramatically. METHODS: Data from all patients undergoing bariatric surgery are introduced prospectively in a data-base. Patients who were reoperated for symptoms or signs suggestive of an internal hernia were reviewed retrospectively, with special emphasis on clinical and radiological findings, and surgical management. RESULTS: Of 607 patients who underwent laparoscopic primary or reoperative RYGBP in our two hospitals between June 1999 and January 2006, 25 developed symptoms suggestive of an internal hernia, 2 in the immediate postoperative period, and 23 later on, after a mean of 29 months and a mean loss of 14.5 BMI units. 9 of the latter presented with an acute bowel obstruction, of which 1 required small bowel resection for necrosis. Recurrent colicky abdominal pain was the leading symptom in the others. Reoperation confirmed the diagnosis of internal hernia in all but 1 patient. The most common location was the meso-jejunal mesenteric window (16 patients, 56%), followed by Petersen's window (8 patients, 27%), and the mesocolic window (5 patients, 17%). Patients in whom the mesenteric windows had been closed using running non-absorbable sutures had fewer hernias than patients treated with absorbable sutures at the primary procedure (1.3% versus 5.6%, P=0.03). Except in the acute setting, clinical and radiological findings were of little help in the diagnosis. CONCLUSIONS: Except in the setting of acute obstruction, clinical and radiological findings usually do not help in the diagnosis of internal hernia. A high index of suspicion, based mainly on the clinical history of recurrent colicky abdominal pain, is the only means to reduce the number of acute complications leading to bowel resection by offering the patient an elective laparoscopic exploration with repair of all the defects. Prevention by carefully closing all potential mesenteric defects with running non-absorbable sutures during laparoscopic RYGBP, which we consider mandatory, seems appropriate in reducing the incidence of this complication.

A 10-year experience with laparoscopic gastric banding for morbid obesity: high long-term complication and failure rates.

BACKGROUND: Since its introduction about 10 years ago, and because of its encouraging early results regarding weight loss and morbidity, laparoscopic gastric banding (LGB) has been considered by many as the treatment of choice for morbid obesity. Few long-term studies have been published. We present our results after up to 8 years (mean 74 months) of follow-up. METHODS: Prospective data of patients who had LGB have been collected since 1995, with exclusion of the first 30 patients (learning curve). Major late complications are defined as those requiring band removal (major reoperation), with or without conversion to another procedure. Failure is defined as an excess weight loss (EWL) of <25%, or major reoperation. RESULTS: Between June 1997 and June 2003, LGB was performed in 317 patients, 43 men and 274 women. Mean age was 38 years (19-69), mean weight was 119 kg (79-179), and mean BMI was 43.5 kg/m(2) (34-78). 97.8% of the patients were available for follow-up after 3 years, 88.2% after 5 years, and 81.5% after 7 years. Overall, 105 (33.1%) of the patients developed late complications, including band erosion in 9.5%, pouch dilatation/slippage in 6.3%, and catheter- or port-related problems in 7.6%. Major reoperation was required in 21.7% of the patients. The mean EWL at 5 years was 58.5% in patients with the band still in place. The failure rate increased from 13.2% after 18 months to 23.8% at 3, 31.5% at 5, and 36.9% at 7 years. CONCLUSIONS: LGB appeared promising during the first few years after its introduction, but results worsen over time, despite improvements in the operative technique and material. Only about 60% of the patients without major complication maintain an acceptable EWL in the long term. Each year adds 3-4% to the major complication rate, which contributes to the total failure rate. With a nearly 40% 5-year failure rate, and a 43% 7-year success rate (EWL >50%), LGB should no longer be considered as the procedure of choice for obesity. Until reliable selection criteria for patients at low risk for long-term complications are developed, other longer lasting procedures should be used.

European experience with laparoscopic Roux-en-Y gastric bypass in 466 obese patients.

BACKGROUND: Roux-en-Y gastric bypass (RYGBP) is usually considered as the procedure of choice for morbid obesity, but its use has been limited in Europe. It is not known whether results with European patients match those from the USA. METHODS: A total of 466 patients were followed prospectively regarding weight loss, co-morbidities, quality of life and morbidity after primary laparoscopic RYGBP. Overall assessment was done using the bariatric analysis and reporting outcome system (BAROS). RESULTS: Conversion to open surgery was necessary in three patients. The overall early morbidity rate was 17.0 per cent and the rate of major complications was 4.7 per cent. The mortality rate was 0.2 per cent. Major morbidity decreased over time. Excess weight loss of over 50 per cent was maintained for up to 4 years in 71.4 per cent of the morbidly obese and 65.2 per cent of the super-obese patients. Co-morbidities resolved or improved in most patients and quality of life improved. At 3 years, the BAROS score was excellent or very good in 77.1 per cent and good in 22.8 per cent. Late complications leading to reoperation developed in 19 patients (4.1 per cent). CONCLUSION: These results are satisfactory and comparable to those reported from the USA. Owing to limitations associated with purely restrictive bariatric procedures, laparoscopic RYGBP is likely to become the procedure of choice for treatment of morbid obesity in Europe.

[Visceral surgery]. / Chirurgie.

Visceral surgery has benefited from several significant therapeutical improvements in 2005. They involve more specifically endocrine surgery, obesity, ovarian cancer, rectocele and cystic pancreatic neoplasia. Minimal invasive surgery is increasingly used, for example in endocrine conditions and obesity treatment. New techniques also emerge, such as electrical gastric stimulation for obesity or Stapled Trans Anal Rectal Resection (STARR) for anterior rectocele. Accurate diagnosis criteria allow better management of cystic pancreatic neoplasia, especially to choose the best treatment of this condition.

Comparison of morphological and functional alterations of human saphenous veins after seven and fourteen days of ex vivo perfusion.

Intimal hyperplasia (IH) is a vessel wall remodeling process responsible of early failure after vascular surgery or endovascular interventions. An ex vivo perfusion was used to study human venous segments regarding functional, histomorphological, immunohistochemical and molecular alterations after 7 (group 1, n = 6) and 14 days (group 2, n = 6) of ex vivo perfusion. All vessel segments showed preserved smooth muscle function before and after perfusion. Histomorphometry revealed IH development which was more pronounced after 14 days rather than 7 days (p < 0.05). Expression of CD34, factor VIII, alpha-actin and MIB-1 was demonstrated in all segments from both groups indicating that muscular and endothelial integrity was preserved after ex vivo perfusion of up to 14 days. PAI-1 mRNA expression was significantly increased after perfusion (p < 0.05), suggesting that the endothelial fibrinolytic function may be modulated in this ex vivo perfusion model of human saphenous veins.