Comparison of results after one year between sleeve gastrectomy and gastric bypass in patients with BMI ≥ 50 kg/m².

BACKGROUND: Although laparoscopic sleeve gastrectomy (LSG) was initially described as the first step of a 2-stage procedure for high-risk patients requiring laparoscopic Roux-en-Y gastric bypass (LRYGB), it is now being used as a single-stage procedure. Experience with laparoscopic bariatric surgery is growing, such that LRYGB is increasingly feasible for patients with body mass index (BMI) ≥ 50 kg/m². Nevertheless, outcomes for such category of patients following LSG and LRYGB are lacking. OBJECTIVE: To compare weight loss and changes in obesity related co-morbidities at one year following LSG with LRYGB in patients with BMI ≥ 50 kg/m². SETTINGS: The prospective database of a single surgery university center was queried for clinical and other relevant data. METHODS: From January 2004 to January 2013, 74 and 285 patients underwent LSG or LRYGB with a BMI ≥ 50 kg/m². At one year, rate of follow-up was 92.8%. Success of surgery was defined as % of excess weight loss (%EWL)≥ 50% at one year. Logistic regression was used to compute odds ratio (OR) to evaluate the success at one year of surgery. RESULTS: LSG (N = 74) and LGBP (N = 285) groups did not differ for initial BMI (57.2 ± 7.1 versus 56.7 ± 5.5 kg/m²; P = .52), % of female (64.6% versus 73.7%, P = .13) or major adverse postoperative events (5.7% versus 6.7%; P = .85). At one year, the mean percentage of weight loss (%) (22.0 ± 7.6 versus 30.3 ± 7.4; P < .0001) and percentage of excess weight loss (%) (40.2 ± 15.2 versus 55.0 ± 14.6; P < .0001) and rates of remission of diabetes (47.5% versus 70.7%; P = .01) were greater in the LGBP than LSG group. In multivariate analyses (OR), LSG was an independent factor of failure of weight loss (.12; P < .0001) CONCLUSION: After 1 year of follow-up in patients with a BMI ≥ 50 kg/m², LRYGB provides better weight loss and resolution in diabetes than LSG with similar postoperative morbidity. Further long-term studies are needed to confirm these results.

Five-year weight loss in primary gastric bypass and revisional gastric bypass for failed adjustable gastric banding: results of a case-matched study.

BACKGROUND: Despite their now frequent use, the long-term results for adjustable gastric bands are variable and often less than gastric bypass. Laparoscopic Roux-en-Y gastric bypass (LRYGB) provides good early results and seems to be the revisional procedure of choice. Nevertheless, the long-term outcomes following revisional LRYGB (rLRYGB) for failed adjustable gastric banding have not been compared with those for primary LRYGB (pLRYGB). METHODS: The objective was to compare weight loss and changes in obesity related co-morbidities 5 years after pLRYGB and rLRYGB for failed adjustable gastric banding. The prospective database of a single surgery university center (Paris, France) was queried for clinical and other relevant data. From January 2004 to September 2008, 58 and 272 patients have undergone rLRYGB and pLRYGB, respectively. Rate of lost to follow-up was 13.3%. We matched 45 patients undergoing rLRYGB (case group) with 45 undergoing pLRYGB (control group) for age, sex, and initial body mass index (BMI). RESULTS: Case and control groups did not differ for initial BMI (46.9±7.2 versus 46.9±7.5 kg/m²; P=.99), age (43.4±9.4 versus 43.6±9.8y; P=.91), or sex ratio (91.1% female, P=.99). The rates of coexisting conditions in the 2 groups were similar. At 5 years, weight loss (kg) (39.9±16.4 versus 31.4±15.8; P=.02), percentage of weight loss (%) (30.8±9.8 versus 24.8±11.5; P=.03), and percentage of excess weight loss (%) (68.4±20.6 versus 55.7±26.3; P=.007) were higher for pLRYGB than rLRYGB. Rates of remission and improvement of coexisting conditions were similar. CONCLUSION: After 5 years of follow-up, pLRYGB provides greater weight loss than rLRYGB with similar rates of improvement and remission of coexisting conditions. Patients and surgeons should be aware of such results before primary and revisional bariatric surgery.

Five-year outcomes of gastric bypass for super-super-obesity (BMI≥60 kg/m²): a case matched study.

BACKGROUND: Laparoscopic gastric bypass (LRYGB) is feasible for patients with body mass index (BMI)≥60 kg/m² (super-super-obesity [SSO]) but long-term data are lacking. The objective of this study was to compare the 5-year weight loss and changes in obesity-related co-morbidities after LRYGB for SSO and non-SSO patients. METHODS: From January 2004 to November 2008, 32 SSO and 320 non-SSO patients underwent LRYGB. We matched 30 SSO patients undergoing LRYGB (case group) with 60 non-SSO patients (control group) for age, sex, and presence of type 2 diabetes. RESULTS: Baseline data indicate that case and control groups did not differ for age (42±12.4 versus 41.8±11.5 yr; P=.92) or sex ratio (80% female, P=.99). Preoperative BMI were 64.1±4.1 and 46.3±5.6 kg/m² in SSO and non-SSO groups, respectively (P<.0001). The rates of coexisting conditions in the 2 groups were comparable except for hypertension (76.7% versus 53.3%; P=.03). At 5 years after surgery, the percentage of initial weight loss (%IWL) (27.4±11.8 versus 29.7±9.2; P=.35) for the groups were comparable whereas percentage of excess weight loss (%EWL) (44.9±19.9 versus 66.5±21.2; P<.0001) was higher for non-SSO patients. Rates of remission or improvement of coexisting conditions, including diabetes and hypertension, did not differ significantly different between groups. CONCLUSION: According to %IWL and rate of partial or complete remission of diabetes and hypertension, our study shows similar outcomes for LRYGB in SSO and non-SSO patients 5 years after surgery. The %EWL does not seem to be an adequate indicator for evaluation of LRYGB outcomes in patients with extreme obesity, such as SSO.

Similar postoperative safety between primary and revisional gastric bypass for failed gastric banding.

IMPORTANCE: Adjustable gastric bands are widely used because of low postoperative morbidity, but their long-term results are poor, often leading to revisional surgery. OBJECTIVE: To assess the safety of revisional procedures by comparing the 30-day outcomes of primary gastric bypass vs revisions following failed adjustable gastric banding. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review using logistic regression models to compute odds ratios (95% CIs) across preoperative body mass index (calculated as weight in kilograms divided by height in meters squared) quartiles to evaluate the risk for major adverse outcomes at 30 days (death, venous thromboembolism, reinterventions, and failure to be discharged). The prospective database of a single university surgical center in Paris, France, was queried for clinical and other relevant data among all patients undergoing primary or revisional laparoscopic gastric bypass between January 1, 2004, and June 30, 2013. MAIN OUTCOMES AND MEASURES: The primary outcome was a comparison between 30-day outcomes of primary gastric bypass and procedures following failed adjustable gastric banding. RESULTS: In total, 831 patients had a primary procedure (group 1), and 177 patients had a secondary procedure after failed adjustable gastric banding (group 2). Overall, 78.7% of patients were female, the mean (SD) patient age was 42.6 (11.6) years, the mean (SD) body mass index was 47.6 (7.6), and mortality at 30 days was 0.5%. The rates of major adverse outcomes were similar in group 1 (7.8%) and group 2 (8.5%) (P = .77). In multivariate analyses, odds ratios for major adverse outcomes across preoperative body mass index quartiles (<42, 42-46, >46 to 52, and >52) were 1.00, 0.39 (95% CI, 0.20-0.77; P = .006), 0.55 (95% CI, 0.30-1.02; P = .06), and 0.50 (95% CI, 0.27-0.94; P = .03), respectively. CONCLUSIONS AND RELEVANCE: The 30-day major adverse outcome rates were similar for primary gastric bypass and for procedures following failed adjustable gastric banding. Long-term comparative studies are required to better understand the quadratic relationship between body mass index and early postoperative outcomes.

Is laparoscopy a safe approach for diffuse appendicular peritonitis? Feasibility and determination of risk factors for post-operative intra-abdominal abscess.

BACKGROUND: Several studies have assessed feasibility and early outcomes of the laparoscopic approach for complicated appendicitis (CA). However, these studies suffer from limitations due to the heterogeneous definitions used for CA. No studies have assessed feasibility and early post-operative outcomes of the laparoscopic approach in the specific management of diffuse appendicular peritonitis (DAP). Consequently, outcomes of the laparoscopic approach for the management of DAP are poorly documented. METHODS: The laparoscopic approach is the first-line standardised procedure used by our team for the management of DAP. All patients (aged >16 years) who underwent laparoscopy for DAP (CA with the presence of purulent fluid with or without fibrin membranes in at least a hemi abdomen) between 2004 and 2012 were prospectively included. Post-operative outcomes were analysed according to the Clavien-Dindo classification. RESULTS: Laparoscopy for DAP was performed for 141 patients. Mean age was 39.6 ± 20 (16-92) years. A total of 45 patients (31.9%) had pre-operative contracture. The mean pre-operative leukocyte count was 14,900 ± 4,380 mm(-3). The mean pre-operative C-reactive protein (CRP) serum concentration was 135 ± 112 (2-418) mg/dl. The conversion rate was 3.5%. The mean operative time was 80 ± 27 (20-180) min. There were no deaths. The rate of grade III morbidity was 6.5%. Ten patients (7.1%) experienced intra-abdominal abscess (IAA); seven of these cases were treated conservatively. The mean length of hospital stay was 6.9 ± 5 (2-36) days. A pre-operative leukocyte count >17,000 mm(-3), and CRP serum concentration >200 mg/dl were significant predictive factors for IAA in multivariate analyses [odds ratio (OR) 25.0, 95% confidence interval (CI) 2.4-250, p = 0.007 and OR 16.4, 95% CI 1.6-166, p = 0.02, respectively]. CONCLUSION: The laparoscopic approach for DAP is a safe and feasible procedure with a low conversion rate and an acceptable rate of IAA in view of the severity of the disease. Pre-operative leukocyte counts >17,000 mm(-3) and pre-operative CRP serum concentrations >200 mg/dl indicate a high risk of IAA.

Lateral incisional hernia repair by the retromuscular approach with polyester standard mesh: topographic considerations and long-term follow-up of 61 consecutive patients.

BACKGROUND: Because of the lack of published data and the relative rarity of lateral incisional hernia (LIH), their repair remains a major challenge for surgeons. The aim of the present study was to evaluate the outcome of LIH treated by the retromuscular approach (RMA) with a polyester standard mesh. METHODS: Sixty-one patients were treated between June 2000 and November 2007 in an academic tertiary referral center using one standardized surgical technique and one type of mesh. Lumbar incisional hernia was excluded. All data were prospectively culled. The early complications and recurrence rates were evaluated. RESULTS: There were 14 (23%) subcostal, 12 (19.6%) flank, and 35 (57.4%) iliac fossa LIH. The mean patient age was 57 years, and 60% were male. The average width of the defect was 7.6 cm and the overall defect size averaged 56 cm². Seventeen patients (28%) had had previous LIH repair. Ten patients had double hernia locations (midline and lateral) repaired simultaneously. The average operative time and hospital stay were 136 min and 7 days, respectively. The early complications rate was 18%. Four patients required reoperation. There were no mesh infections. The median follow-up was 47 months (range: 1-125 months). Recurrence was observed in three patients (4.9%). CONCLUSIONS: LIH repair by RMA with a polyester heavyweight mesh proves to be a safe treatment with a moderate complication rate and a low infection rate, even in the treatment of large or multifocal parietal defects.

Retromuscular mesh repair of midline incisional hernia with polyester standard mesh: monocentric experience of 261 consecutive patients with a 5-year follow-up.

BACKGROUND: Midline incisional hernia (MIH) repair remains a major challenge for surgeons. Multiple procedures and types of mesh to treat incisional hernia are available. We evaluated outcomes of MIH treated by retromuscular mesh repair (RMR) using a polyester standard prosthesis. PATIENTS: A total of 262 patients were treated for MIH by RMR between June 2000 and November 2007 in an academic tertiary referral center using the same standardized surgical technique and one type of mesh. The early complications and recurrence rate were evaluated. RESULTS: The average patient age was 57 years; 51% were women. The mean width was 7.8 cm and defect size was 61 cm². Previous MIH repair had been performed in 23% of the patients. Average hospital stay was 7 days. Of the 262 patients studied, 34 patients (13%) developed early complications, and 16 required reoperation for various indications. Early mesh infection occurred in 2 patients (0.8%) requiring mesh removal. The mean follow-up was 58 months. Recurrence was observed in 8 patients (3%) with an average delay of 19 months. There was a significant difference in terms of recurrence in patients with mesh infection versus the group who did not develop infection (2/2 patients versus 6/259; P < 0.001). CONCLUSIONS: Our results suggest that RMR with a polyester standard prosthesis for MIH remains a safe "classic" treatment with a moderate complication rate and a low infection and recurrence rate, even in large incisional hernia.

Etonorgestrel concentrations in morbidly obese women following Roux-en-Y gastric bypass surgery: three case reports.

BACKGROUND: Pregnancy should be avoided for 12 to 18 months after Roux-en-Y gastric bypass (RYGB) surgery. The etonorgestrel (ENG)-releasing implant (Implanon®) may represent a safe and effective contraceptive method in morbidly obese women who are candidates for bariatric surgery. In addition, the subcutaneous delivery of steroid is unaffected by malabsorptive surgery. METHODS: Three cases of young women with ENG-releasing implant are reported. The device was inserted 1-2 months prior to RYGB. RESULTS: Their initial weights were 130 to 176 kg, and the mean weight loss was 33.6 kg at 6 months. The concomitant serum ENG concentrations decreased currently with weight loss but remained above the minimum concentration required for effective contraceptive effect of the implant for at least 6 months following RYGB (average, 170 pg/mL). The concentrations observed before weight loss were lower than in normal-weight women, but decreases in ENG concentrations following implant insertion were similar. CONCLUSION: These unique data in morbidly obese women highlight the need for further pharmacokinetic studies of contraceptive agents in obese women during weight loss.

Prognostic significance of 18q LOH in sporadic colorectal carcinoma.

Identification of molecular alterations with implication for prognosis and sensibility to chemotherapeutic agents represents a great challenge in colorectal carcinoma treatment. Controversial results have been reported on prognostic value of chromosome 18q loss. Ninety-seven unselected patients with sporadic colorectal carcinoma Stage II and III were investigated for loss of heterozygosity at 18q D18S58 and D18S61 loci. Molecular alterations were correlated with clinicopathological data and survival. 18q loss of heterozygosity (LOH) was present in 56 per cent cases of carcinoma and was not related either to the clinicopathological characteristics of the patients or to prognosis. However, patients with LOH at locus D18S61 showed a more favorable prognosis. This finding was especially true for Stage II and untreated carcinoma. Survival was not influenced by the status of D18S58 locus. In our series, LOH at chromosome 18q does not seem to predict an unfavorable outcome. It seems of special interest the benefit that D18S61 loss of heterozygosity confers to untreated patients and patients with Stage II colon carcinoma.

[Bariatric surgery: surgical techniques and their complications]. / Chirurgie bariatrique: techniques chirurgicales et leurs complications.

Bariatric surgery is the only treatment permitting significant and long lasting results for patients suffering from morbid obesity. Indications are BMI>40 kg/m(2) or BMI >35 kg/m(2) associated with one or multiples comorbidities. In all cases, a multidisciplinary approach is required. Laparoscopic surgery because of its mini-invasive nature is a significant improvement for early and late postoperative courses. Adjustable gastric banding, gastric by-pass, sleeve gastrectomy, bilio-pancreatic diversions are in this order the most frequent bariatric procedures performed in France. Severe and early surgical complications are dominated by occlusions and anastomotic leakages. Late complications are dominated by small bowel occlusions. Early medical complications are thrombo-embolism manifestations. Late medical complications are vitamin and trace elements deficiencies. Severe complications are due to pauci-symptomaticity of patients and their poor clinical status. Every practitioner taking care of these patients have to know all principles, specificity and complications of this kind of surgery.

Value of a systematic operative protocol for cocaine body packers.

BACKGROUND: Internal concealment of illicit drugs during international drug traffic represents an important problem in developed countries. These drug traffickers are called "body packers." The aim of this study was to analyze retroprospectively the surgical indications and complications for cocaine body packers and to describe our systematic operative protocol. METHODS: From January 1997 to December 2005, 1,181 cocaine body packers were admitted to our Medico-Judiciary Emergency Department. All patients had the same medical surveillance protocol. Nineteen patients required surgical procedure to remove drug packets. RESULTS: Thirteen patients had obstruction or intestinal retention (68%). Suspicion of packet rupture or cocaine intoxication occurred in six patients (32%). Zero to three enterotomies were necessary during laparotomy. No deaths occurred. One pouch abscess required relaparotomy and one wound abscess was treated medically. The median hospital stay was 7 days (range: 5-30 days). CONCLUSIONS: Few cocaine body packers required a laparotomy. Our systematic operative protocol allowed intestinal clearance and caused acceptable morbidity rate.

Prognostic evaluation of the new American Joint Committee on Cancer/International Union Against Cancer staging system for hepatocellular carcinoma: analysis of 112 cirrhotic patients resected for hepatocellular carcinoma.

BACKGROUND: In 2002, the American Joint Committee on Cancer and the International Union Against Cancer redefined the T-classification for hepatocellular carcinoma, shifting the cutoff value for tumor size from 2 to 5 cm and giving more emphasis to vascular invasion. METHODS: A retrospective cohort study was conducted on 223 consecutive patients with hepatocellular carcinoma observed between 1990 and 2002. One hundred twelve were resected and considered for retrospective analysis. Univariate and multivariate analyses were performed on several clinicopathologic variables. After classification according to each staging system, the long-term survival of different stages was compared. The prognostic value of each staging system was further evaluated by entering each stage, in turn, into the Cox regression model with other clinicopathologic variables. The median follow-up was 19 months. RESULTS: On multivariate analysis, the viral etiology of cirrhosis and the presence of multiple nodules were independent prognostic factors. When the new staging system was entered into the multivariate analysis, it was the only independent factor (P = .02). When stratified according to the old tumor-node-metastasis system, there were no significant differences in the survival between stage I and II (P = .14) or between stage IIIA and IVA (P = .33); only the survival of stage II and IIIA was different (P < .01). When stratified according to the new tumor-node-metastasis system, there were significant differences between stage I and II (71.7% vs. 54.7%; P = .02). CONCLUSIONS: The new staging system is a more reliable and objective method for T classification. It is easy to use in clinical practice and is better at stratifying curatively resected patients with respect to prognosis.

[Prognostic factors and long term outcome after surgery for hilar cholangiocarcinoma. Univariate and multivariate analysis]. / Fattori prognostici clinico-patologici e risultati a distanza dopo resezione per colangiocarcinoma ilare. Analisi univariata e multivariata.

Aim of the study was to evaluate the surgical strategy for the treatment of the hilar cholangiocarcinoma, focusing on the clinicopathological factors influencing the outcome. Between January 2001 and December 2003 23 patients out of 33 underwent surgery for hilar cholangiocarcinoma. All patients underwent resection of the extrahepatic biliary duct. This was the only treatment in patients with Bismuth-Corlette type I cholangiocarcinoma, or in patients not suitable for hepatic resection. In the other cases, resection of extrahepatic bile duct was associated to right or left hepatectomy. The univariate and multivariate analysis evaluated multiple clinicopathological factors in order to assess long term survival. Major hepatic resection was carried out in 19 (82%) patients. Hepatic resection extended to the segment 4 was performed in 5 patients. Also, left hepatectomy was carried out in 14 patients, while resection of the caudate lobe in 7 (30%) patients. No hospital mortality was recorded, while the overall morbidity was 43%. The 1 year survival rate was 63.2%, and the median survival rate 19 months. Recurrencies showed up in 12 patients (52%). Among the other factors, low level of albumin (p = 0.006), positive resection margins (p = 0.003) and T (p = 0.02) mostly affected the long term survival. Surgery is the gold standard for achieving curative treatment of hilar cholangiocarcinoma. The bile duct resection, along with hepatic resection, the best option to increase long term survival of these patients. The univariate and multivariate analysis showed that low albumin levels, positive resection margins and T are the most important factors influencing long term survival.

Minimally invasive surgical treatment of esophageal achalasia.

BACKGROUND AND OBJECTIVES: A minimally invasive approach is considered the treatment of choice for esophageal achalasia. We report the evolution of our experience from thoracoscopic Heller myotomy (THM) to laparoscopic Heller myotomy (LHM). Our objective is to define the efficacy and safety of these 2 approaches. METHODS: Between March 1993 and December 2001, 36 patients underwent minimally invasive surgery for achalasia. Sixteen patients underwent THM without an antireflux procedure, and 20 patients underwent LHM with partial anterior fundoplication (n = 13) or closure of the angle of His (n = 7). RESULTS: Mean operative time and mean hospital stay were significantly shorter for LHM compared with that of THM (148.3 +/- 38.7 vs 222 +/- 46.1 min, respectively; P = 0.0001) and (2.06 +/- 0.65 days vs 5.06 +/- 0.85 days, respectively; P = 0.0001). Six of 16 patients (37.5%) in the THM group experienced persistent or recurrent dysphagia compared with 1 of 20 patients (5%) in the LHM group (P = 0.01). Heartburn developed in 5 patients (31.2%) after THM and in 1 patient (5%) after LHM (P = 0.06). Regurgitation developed in 4 patients (25%) after THM and in 2 patients (10%) after LHM (P = 0.2). Lower esophageal sphincter (LES) basal pressure decreased significantly from 30.1 +/- 5.07 to 15.3 +/- 2.1 after THM and from 31.8 +/- 6.2 to 10.4 +/- 1.7 after LHM (P = 0.0001). Mean esophageal diameter was significantly reduced after LHM compared with that after THM (from 53.9 +/- 5.9 mm to 27.2 +/- 3.3 mm vs 50.8 +/- 7.6 mm to 37.2 +/- 6.9 mm respectively: P = 0.0001). CONCLUSION: In our experience, LHM is associated with better short-term results and is superior to THM in relieving dysphagia. LHM with partial anterior fundoplication should be considered the treatment of choice for achalasia.

Hemoperitoneum from a spontaneous rupture of a giant hemangioma of the liver: report of a case.

Hemangioma is the most common benign tumor of the liver and it is often asymptomatic. Spontaneous or traumatic rupture, intratumoral bleeding, consumption coagulopathy, and rapid growth are mandatory surgical indications. We report a case of giant hemangioma of hepatic segments II and III, which presented as hemoperitoneum, and were treated successfully with preoperative transcatheter arterial embolization (TAE) and hepatic bisegmentectomy. A PubMed Medline search has identified up to now 32 cases of spontaneous rupture of hepatic hemangioma in adults (age >14 years) without a history of trauma, including the present case. Twenty-seven out of these were reviewed. Sixteen (84.2%) of 19 tumors of known size were giant hemangiomas (mean diameter 14.8 cm; range 6-25). Twenty-two (95.7%) patients underwent surgery. Thirteen patients (59.1%) had a resection, 5 (22.8%) were sutured, and 4 (18.1%) underwent tamponade. Three (23%) out of the 13 resected patients died. Four patients (30.8%) underwent TAE prior to elective hepatic resection without any operative mortality. Among the 5 sutured patients, 2 (40%) died as well as 3 (75%) out of 4 patients who underwent tamponade. The mortality rate of all surgery patients was 36.4% (8/22).

Surgical treatment of hepatocellular carcinoma in elderly cirrhotic patients: personal experience.

BACKGROUND: Due to the longer life expectancy of the world's population, the number of elderly cirrhotic patients undergoing surgery for hepatocellular carcinoma (HCC) is increasing. Our study evaluates the benefits of hepatic resections for HCC in cirrhotic patients aged over 65, analysing the early and long-term surgical results. PATIENTS AND METHODS: We retrospectively considered a series of 46 patients receiving hepatic resection for HCC. The clinicopathological data and surgical outcome of 14 (30.4%) patients aged 65 or older (group I) were evaluated and compared to the 32 (69.6%) younger than 65 (group II). RESULTS: No operative mortality was recorded in either group. The hospital mortality rate was 7.1% (1 out of 14) in group I and 9.4% (3 out of 32) in group II (p = 1.00). Hospital morbidity did not differ significantly in the two groups (21.4% vs 34.4%; p = 0.50). At follow-up (median 34 months, interquartile range: 12-63) 3 patients from group I (21.4%) and 16 patients from group II (50%) experienced tumor recurrence (p = 0.14). The five-year disease-free survival rate for group I and group II was 71.4% vs 28.2%, respectively (p = 0.05). The overall 5-year survival rate for group I and group II was, respectively, 77.4% vs 41.8%, (p = 0.3). CONCLUSION: Elderly cirrhotic patients with HCC can benefit from hepatic resection as well as younger patients; age by itself should not be considered a contraindication to surgery.