Early small bowel obstruction in laparoscopic Roux-en-Y gastric bypass.

Alimentary limb kinking after laparoscopic Roux-en-Y gastric bypass suggested by CT-scan and diagnosed at laparoscopic surgery. Surgical treatment principles.

Management of massive small bowel bleeding: A case of multidisciplinary approach with mini-invasive surgery.

A 78-year-old patient had a massive small bowel bleeding on CT scan. A multidisciplinary approach was purposed, with a super-selective tracking with methylene blue, haemostatic control with embolization, followed by laparoscopy. Evolution was favorable, there was no recurrence.

Evaluation of risk factors for complications after bariatric surgery.

The decision to perform a bariatric surgical procedure, the conclusion of a clinical pathway in which management is individually adapted to each patient, is taken after multidisciplinary consultation. Paradoxically, the patients who would most benefit from surgery are also those who have the highest operative risk. In practice, predictive factors of mortality and severe postoperative complications (Clavien-Dindo>III) must be used to evaluate the benefit/risk ratio most objectively. The main risk factors are age, male gender, body mass index, obstructive sleep apnea syndrome, insulin resistance and diabetes, tobacco abuse, cardiovascular disease, ability to lose weight before surgery, hypoalbuminemia and functional disability. Routine preoperative evaluation of high perioperative risk patients provides the attending physician with information to: (1) correct several of these risk factors before surgery and thereby limit the operative risk; (2) orient the patient to a less risky surgical procedure and/or to a facility with a more adapted technical capacity, as necessary; (3) contra-indicate the operation if the risks exceed the expected benefits. All in all, this preoperative evaluation combined with management of comorbidities contributes to decrease the risk of postoperative complications and to improve the overall management of obese patients.

Abdominoplasty and simultaneous laparoscopic ventral hernia repair. Clinical study about 45 patients.

INTRODUCTION: Abdominoplasty procedures sometimes reveal the presence of ventral hernias (umbilical or trocar-site hernias). Our objective is then to deal with the excess abdominal skin and fat tissue at the same time as the ventral hernia. This can be done with a single surgical procedure combining abdominoplasty with umbilical transposition and laparoscopic ventral hernia repair (LVHR) with mesh. The main objective of our study is to assess the outcome of the combined procedure of abdominoplasty and LVHR with mesh, compared to abdominoplasty alone. MATERIALS AND METHODS: A retrospective single-centre cohort study was conducted, including patients operated on with the combined method (ABDO-LVHR group) and patients who underwent abdominoplasty alone (ABDO group). We noted major and minor complications, with infection issues as our main concern. RESULTS: We included 15 patients in the ABDO-LVHR group and 30 in the ABDO group. The results show no statistically significant difference for infectious complications in the ABDO-LVHR group compared to the ABDO group (20% vs 3.3%; P=0.100). There was no instance of complete umbilical necrosis. Other major and minor complications occurred at the rates typically described in the literature without difference between the two groups. CONCLUSION: There was no significant difference between our two groups in terms of infectious complications. LVHR carried out at the same time as abdominoplasty with umbilical transposition is a positive combination of procedures. Further studies are necessary to confirm that the risk in terms of infectious complications is no higher than for abdominoplasty alone. LEVEL OF EVIDENCE: III.

Second-stage robot-assisted biliopancreatic diversion with duodenal switch after sleeve gastrectomy.

Biliopancreatic diversion (BPD) was initially described in 1979 and consisted of a distal gastrectomy with a 250-mL stomach pouch and a distal intestinal bypass with a 50 to 100-cm common channel resulting in malabsorption of dietary fat (Scopinaro et al. Br J Surg. 66(9):618-20, 1979). Later, several modifications (sleeve gastrectomy, pylorus preservation, and duodenal switch) were proposed to improve incidence of postoperative dumping syndrome, diarrhea, and anastomotic ulcerations (Lagacé et al. Obes Surg. 5(4):411-8, 1995). Gagner et al. developed a simplified and reproducible approach for laparoscopic BPD with duodenal switch (BPD-DS) after sleeve gastrectomy (Ren et al. Obes Surg. 10(6): 514-23, 2000). BPD-DS has been considered as one of the most difficult bariatric procedures for its surgical complexity and postoperative metabolic complications management. In this regard, the number of BPD-DS has remained extremely low (<4 %). We hypothesize that robotic approach could facilitate the feasibility of BPD-DS procedure. In this multimedia video (8 min), we present a step-by-step robotic BPD-DS.

Risk Factors for Postoperative Morbidity After Totally Robotic Gastric Bypass in 302 Consecutive Patients.

BACKGROUND: Totally robotic gastric bypass (robotic Roux-en-Y gastric bypass, R-RYGBP) has been adopted in some centers on the basis of large retrospective studies. In view of some data showing higher morbidity and higher costs, some authors have considered that robotic gastric bypass may no longer be justified with the existing system. Although low postoperative complication rates after R-RYGBP have been reported, risk factors for postoperative morbidity have never been evaluated. The goal of this study was to identify risk factors for postoperative morbidity after R-RYGBP. METHODS: A retrospective analysis of a prospectively maintained database was performed and included 302 consecutive patients after R-RYGBP performed between 2007 and 2013. This subset of patients represented 34 % of all gastric bypass procedures performed during this study period. Univariate and multivariate analyses were performed in order to identify risk factors for postoperative overall morbidity (Clavien scores 1-4 versus 0) and major morbidity (Clavien score ≥3 versus 0-1-2). RESULTS: Postoperative morbidity and mortality rates were 24.4 and 0.6 %, respectively. In multivariate analysis, independent risk factors for overall morbidity were American Society of Anesthesiologists (ASA) score ≥3 (odds ratio (OR) 2.0) and previous bariatric surgery (revisional gastric bypass) (OR 2.0). Independent risk factors for major morbidity (Clavien ≥3) were previous bariatric surgery (revisional gastric bypass) (OR 3.7), low preoperative hematocrit level (OR 0.9), and revisional gastric bypass procedure with concomitant gastric banding removal (OR 5.7). CONCLUSIONS: R-RYGBP is prone to increased complications in the setting of a high preoperative ASA score and revisional surgery. This should be taken into consideration by clinicians when evaluating R-RYGBP.

Medical follow up after bariatric surgery: nutritional and drug issues. General recommendations for the prevention and treatment of nutritional deficiencies.

This review is an update of the long-term follow-up of nutritional and metabolic issues following bariatric surgery, and also discusses the most recent guidelines for the three most common procedures: adjustable gastric bands (AGB); sleeve gastrectomy (SG); and roux-en-Y gastric bypass (GBP). The risk of nutritional deficiencies depends on the percentage of weight loss and the type of surgical procedure performed. Purely restrictive procedures (AGB, SG), for example, can induce digestive symptoms, food intolerance or maladaptative eating behaviours due to pre- or postsurgical eating disorders. GBP also has a minor malabsorptive component. Iron deficiency is common with the three types of bariatric surgery, especially in menstruating women, and GBP is also associated with an increased risk of calcium, vitamin D and vitamin B12 deficiencies. Rare deficiencies can lead to serious complications such as encephalopathy or protein-energy malnutrition. Long-term problems such as changes in bone metabolism or neurological complications need to be carefully monitored. In addition, routine nutritional screening, recommendations for appropriate supplements and monitoring compliance are imperative, whatever the bariatric procedure. Key points are: (1) virtually routine mineral and multivitamin supplementation; (2) prevention of gallstone formation with the use of ursodeoxycholic acid during the first 6 months; and (3) regular, life-long, follow-up of all patients. Pre- and postoperative therapeutic patient education (TPE) programmes, involving a new multidisciplinary approach based on patient-centred education, may be useful for increasing patients'long-term compliance, which is often poor. The role of the general practitioner has also to be emphasized: clinical visits and follow-ups should be monitored and coordinated with the bariatric team, including the surgeon, the obesity specialist, the dietitian and mental health professionals.

[A serious late complication of non-operative management of splenic trauma: rupture of splenic artery aneurysm]. / Une complication tardive et grave du traitement non-opératoire des traumatismes spléniques: la rupture d'un anévrysme de l'artère splénique.

Over the last five past years, three patients required urgent operation in our institution for hemorrhagic shock after rupture of a post-traumatic splenic artery aneurysm. Those patients had undergone non- operative management (NOM) of grade III, IV (AAST classification) splenic injury 9, 13, and 22 months earlier. Two of them had a CT scan 30 days after initial trauma with no evidence of a developing splenic artery aneurysm. All three patients survived after proximal ligature of splenic artery and hemostatic splenectomy. Our experience with these three cases suggests that a delayed follow-up for patients at high risk is indicated in order to prevent this dramatic complication by early intervention. The modality of this follow-up should be determined by a prospective multicenter study.

[The place of laparoscopy in the management of the patients with penetrating abdominal trauma]. / Place de la laparoscopie dans la prise en charge des blessés par arme blanche de la paroi abdominale antérieure.

INTRODUCTION: In patients with an abdominal knife wound, the main problem is to determine whether the abdominal trauma is penetrating. The aim of this work is to study the safety of the laparoscopic approach in the management of abdominal knife trauma. MATERIALS: A laparoscopy was performing in sixty patients. Patients were dispatched in four categories according to the laparoscopic findings. A laparotomy was performed after laparoscopy in case of peritoneal tear. RESULTS: Unnecessary laparotomy was avoided in 58% of the patients. The follow-up was favourable with nil mortality and a low morbidity (3%). CONCLUSION: Laparoscopic management of abdominal wound knife trauma is a reliable approach to identify a peritoneum tear. This specific situation requires a laparotomy to look for an intra abdominal tear.

[Intra-thoracic fracture-dislocation of the humeral head: a case report and review of the literature]. / Fracture-luxation intrathoracique de la tête humérale: à propos d'un cas et revue de la littérature.

A 50-year-old male traffic accident victim sustained high-energy trauma leading to intra-thoracic fracture-dislocation of the humeral head. Dislocation of the humeral head into the thoracic cavity is a very rare injury. Only twelve cases have been reported in the literature. Treatment modalities vary and no guidelines have been proposed. The mechanism of the injury and the treatment options are discussed together with a review of the literature.

Temporary intestinal occlusion induced by a "patency capsule" in a patient with Crohn's disease.

A 26-year-old woman was admitted for the investigation of abdominal symptoms related to ileal Crohn's disease. The patient had been diagnosed 3 years previously with systemic sclerosis, and had been experiencing digestive complaints for 6 months. A first computed tomography (CT) scan showed ileal intestinal mucosal alterations, associated with a sclerolipomatosis and suspicion of ileal stenosis. An ileocolonoscopy was then performed and showed ulcers in the terminal ileum with nonspecific inflammatory changes found on biopsies, both suggesting the diagnosis of Crohn's disease. The patient was admitted for M2A capsule endoscopy, in order to clarify the respective roles of systemic sclerosis and Crohn's disease with regard to the symptoms and secondarily to determine the anatomical extent of the Crohn's lesions. A patency capsule was administered, for detection of intestinal stenosis before capsule endoscopy was done. At 30 hours after capsule ingestion, the patient complained of abdominal pain and nausea and experienced intestinal obstruction due to the blockage of the patency capsule in the ileal stenosis. The capsule dissolved after 76 hours and the patient then improved. After a few days, the patient underwent ileocecal resection. Pathological examination of the surgical specimen confirmed the presence of an ileal stenosis 17 cm in length. In some circumstances a patency capsule may dissolve slowly, leading to transitory intestinal obstruction requiring medical intervention. It should thus be used cautiously under clinical surveillance in patients with Crohn's disease.

[CT diagnosis of acute gastric volvulus]. / Diagnostic tomodensitométrique d'un volvulus gastrique idiopathique aigu.

Acute gastric volvulus is an infrequent entity. Management is surgical. Diagnosis frequently is delayed because of the non-specific nature of presenting symptoms. The authors report a case of acute gastric volvulus diagnosed by computed tomography in a 92 year old woman that was confirmed at surgery. The pathophysiology, classification and different presentations of this entity are briefly reviewed. CT findings suggesting gastric volvulus are reviewed as well.

[Dynamic graciloplasty in the treatment of severe fecal incontinence. French multicentric retrospective study]. / La graciloplastie dynamisée dans le traitement de l'incontinence fécale sévère. Etude rétrospective multicentrique française.

UNLABELLED: The aim of this study was to retrospectively assess the safety and efficacy of dynamic graciloplasty performed in 5 French surgical centers involved in the treatment of fecal incontinence. PATIENTS AND METHODS: Between March 1994 and March 2000, a total of 24 patients were treated with dynamic graciloplasty for fecal incontinence excluding case of anal reconstruction for cancer. Intramuscular leads and neurostimulators were implanted to stimulate the transposed gracilis. Continence and safety were evaluated using patients' records during hospitalisation and during the out-patient visit or further hospitalisation. RESULTS: No death occurred. A successful functional outcome was reported for 19 patients (79%) during the follow up period. Twenty-two complications occurred including wound. Wound infection in 6 patients and tendon detachment in 4. One patient presented with an infected anal erosion leading to material explantation. CONCLUSION: Dynamic graciloplasty is an effective procedure for patients with refractory fecal incontinence. However, the procedure has significant morbidity which seems to be correlated with the surgeons' experience. Moreover, this procedure should now be compared to the artificial anal sphincter.