Fully ambulatory robotic single anastomosis duodeno-ileal bypass (SADI): 40 consecutive patients in a single tertiary bariatric center.

BACKGROUND: Single Anastomosis Duodeno-Ileal bypass (SADI) is becoming a key option as a revision procedure after laparoscopic sleeve gastrectomy (LSG). However, its safety as an ambulatory procedure (length of stay < 12 h) has not been widely described. METHODS: A prospective bariatric study of 40 patients undergoing SADI robotic surgery after LSG with same day discharge (SDD), was undertaken in April 2021. Strict inclusion and exclusion criteria were applied and the enhanced recovery after bariatric surgery protocol was followed. Anesthesia and robotic procedures were standardized. Early follow-up (30 days) analyzed postoperative (PO) outcomes. RESULTS: Forty patients (37 F/3 M, mean age: 40.3yo), with a mean pre-operative BMI = 40.5 kg/m2 were operated. Median time after LSG was 54 months (21-146). Preoperative comorbidities included: hypertension (n = 3), obstructive sleep apnea (n = 2) and type 2 diabetes (n = 1). Mean total operative time was 128 min (100-180) (mean robotic time: 66 min (42-85)), including patient setup. All patients were discharged home at least 6 h after surgery. There were four minor complications (10%) and two major complications (5%) in the first 30 days postoperative (one intrabdominal abscess PO day-20 (radiological drainage and antibiotic therapy) and one peritonitis due to duodenal leak PO day-1 (treated surgically)). There were six emergency department visits (15%), readmission rate was 5% (n = 2) and reintervention rate was 2.5% (n = 1) There was no mortality and no unplanned overnight hospitalization. CONCLUSIONS: Robotic SADI can be safe for SDD, with appropriate patient selection, in a high-volume center.

Single Anastomosis Duodeno-Ileal bypass (SADI-S) as Primary or Two-Stage Surgery: Mid-Term Outcomes of a Single Canadian Bariatric Center.

PURPOSE: Compare primary single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) and two-stage SADI after sleeve gastrectomy (SG) in terms of weight loss, reduction/remission of comorbidities, and morbidity. METHODS: Retrospective study including 179 patients treated laparoscopically between 2016 and 2020. A 50Fr bougie was used for the SG in the primary SADI-S (group 1) and 36/40Fr for the two-stage procedure (group 2). The duodeno-ileal anastomosis was performed at 250 cm from the ileocecal valve and at least 2 cm after the pylorus. RESULTS: Mean age was 44.1 years old, and there were 148 women and 31 men. There were 67 (37.4%) patients in group 1 and 112 (62.6%) in group 2, with 67% completing the 4-year follow-up. Mean preoperative body mass index (BMI) was 51.1 kg/m2 and 44.6 kg/m2 for groups 1 and 2, respectively. Preoperative comorbidities were obstructive sleep apnea, hypertension, type 2 diabetes, and dyslipidemia in 103 (57.5%), 93 (52%), 65 (36.3%), and 58 (32.4%) of cases. At 4 years postoperatively, excess weight loss (EWL) was 67.5% in group 1 and 67% in group 2 (p = 0.1005). Both groups had good comorbidity remission rates. Early postoperative morbidity rate was 10.4% in group 1 and 3.6% in group 2. In group1, there were mostly postoperative intra-abdominal hematomas managed conservatively (n = 4). Two revisional surgeries were needed for duodeno-ileal anastomosis leaks. Postoperative gastroesophageal reflux disease (GERD), daily diarrhea, vitamin, and protein levels were similar in both groups. CONCLUSION: Both types of strategies are efficient at short and mid-term outcomes. Preoperative criteria will inform surgeon decision between a primary and a two-stage strategy.

Long-term follow-up of a cohort with post sleeve gastrectomy leaks: results of endoscopic treatment and salvage surgery.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is the most performed bariatric procedure worldwide. The most challenging postoperative complication is gastric leak. The objectives of this study are to examine the efficacy and morbidity of different therapeutic strategies addressing leakage, and the long-term outcomes of a cohort of LSG leaks. METHODS: A retrospective review of patients treated for LSG leaks between September 2014 and January 2023 at our high-volume bariatric surgery center was performed. RESULTS: The charts of 37 patients (29 women and 8 men) were reviewed, with a mean age of 43 years and a median follow-up of 24 months. The mean preoperative body mass index was 45.1 kg/m2. Overall, 30/37 (81%) patients were successfully treated with endoscopic management, and 7/37 (19%) ultimately underwent salvage surgery. If the leak was diagnosed earlier than 6 weeks, endoscopic treatment had a 97% success rate. The median number of endoscopic procedures was 2 per patient, and included internal pigtails, stents, septoplasty, endoluminal vacuum therapy and over-the-scope clips. Complications included stent-related ulcers (10), esophageal stenosis requiring endoscopic dilatations (4), stent migrations (2) and kinking requiring repositioning (1), and internal pigtail migration (3). Revisional surgery consisted of proximal gastrectomy and Roux-en-Y esophago-jejunal anastomosis, Roux-en-Y fistulo-jejunostomy or classic Roux-en-Y gastric bypass proximal to the gastric stricture. In 62% of the cases, the axis/caliber of the LSG was abnormal. Beyond 4 attempts, endoscopy was unsuccessful. The success rate of endoscopic management dropped to 25% when treatment was initiated more than 45 days after the index surgery. CONCLUSIONS: Purely endoscopic management was successful in 81% of cases; with 97% success rate if diagnosis earlier than 6 weeks. After four failed endoscopic procedures, a surgical approach should be considered. Delayed diagnosis appears to be a significant risk factor for failure of endoscopic treatment.

Five-year outcomes after surgery for class 1 obesity: a retrospective analysis of a Canadian bariatric centre's experience.

BACKGROUND: There is a paucity of literature exploring the role of bariatric surgery in class 1 obesity. We evaluated the 5-year outcomes after bariatric surgery in patients with class 1 obesity, assessing weight loss, resolution/reduction of obesity-related comorbidities, morbidity and mortality. METHODS: We performed a single-centre retrospective analysis of patients who underwent bariatric surgery (laparoscopic sleeve gastrectomy [LSG] or laparoscopic Roux-en-Y gastric bypass [LRYGB)]) for class 1 obesity (body mass index [BMI] 30.0-34.9) between January 2012 and February 2019. RESULTS: Thirty-seven patients (35 [95%] female, mean age 44.5 yr [standard error (SE) 11.3 yr], mean preoperative BMI 33.1) were included, of whom 32 underwent LSG and 5 underwent LRYGB. Thirty-five patients were followed for 5 years post-operatively, achieving a mean BMI of 25.6 (SE 1.2) and excess weight loss of 89.4% (SE 15.1%). Remission of hypertension was achieved in 5 of 12 patients (42%), and remission of dyslipidemia was achieved in 7 of 11 patients (64%). Of the 11 patients with diabetes, 7 underwent LSG and 4, LRYGB. At 5 years postoperatively, the mean glycosylated hemoglobin concentration was 6.3%. Four patients in the LSG group developed de novo reflux, 1 patient required conversion to LRYGB, and 1 patient with sleeve stenosis required endoscopic dilatation. There were no deaths in either patient group. CONCLUSION: At our centre, bariatric surgery for class 1 obesity was safe and had long-term efficacy, with remission or reduction of related comorbidities. Prospective controlled trials are required to confirm these results.

The Development of a Novel Bariatric Laparoscopic Simulator.

Bariatric surgery presents a specific challenge in surgical education; simulators need to take into account the specific technical difficulties related to the patient population but also to various types of surgery. We interviewed several leaders in the fields of bariatric and general surgery with experience in laparoscopic surgery and developed a bariatric-specific laparoscopic simulator. This novel simulator was constructed using a variety of silicone-based materials and 3D printing techniques to be reusable and adjustable for a variety of procedures, with no essential components being disposed of following each use. Expert surgeons (n=4) with knowledge on bariatric procedures were recruited and asked to perform a simple simulated laparoscopic procedure. Following testing, participants were asked to complete a survey and rate the simulator based on its physical attributes, global realism, usefulness in improving surgical skills, and overall surgical experience. Face and content validation outcomes based on the questionnaire evaluations completed by expert surgeons showed very good results, with an overall mean score of 4.3 out of 5 (86%). These preliminary results highlight the potential for the simulator's application as a tool to improve bariatric surgical education and patient outcomes.

A description of the first Candida auris-colonized individuals in New York State, 2016-2017.

Candida auris (C. auris) is a globally emerging multidrug-resistant yeast. New York State (NYS) first detected C. auris in July 2016 and is the state most affected. This brief report describes characteristics of the first 114 individuals colonized with C. auris identified through active surveillance/screening by NYS Department of Health. "Colonized/screened" individuals were old (median age, 74 year), had extensive health care exposures and underlying conditions (multiple health care facility admissions in the 90 days prior with more than 80% requiring mechanical ventilation), and had 30- and 90-day mortality rates of 17.5% and 37.7%, respectively (with approximately 60% expired in the 2-year follow-up period). This description is helpful to inform additional prevention measures and add to the collective understanding of C. auris in the United States.

A reliable, reproducible flow cytometry protocol for immune cell quantification in human adipose tissue.

The ability to accurately identify and quantify immune cell populations within adipose tissue is important in understanding the role of immune cells in metabolic disease risk. Flow cytometry is the gold standard method for immune cell quantification. However, quantification of immune cells from adipose tissue presents a number of challenges because of the complexities of working with an oily substance and the rapid deterioration of immune cell viability before analysis can be performed. Here we present a highly reproducible flow cytometry protocol for the quantification of immune cells in human adipose tissue, which overcomes these issues.

Case Report: Endoscopic Removal of an Eroded Gastric Band Causing Small Bowel Obstruction upon Migration into the Proximal Jejunum.

BACKGROUND: Adjustable gastric banding (AGB) is on the decline due to its relatively modest amount of expected weight loss, coupled with high rates of revision and complications such as band erosion. Management of eroded gastric bands can be challenging especially when complete intra-gastric erosion is followed by distal migration causing small bowel obstruction. METHODS: We present an endoscopic option of using a pediatric colonoscope to remove an eroded AGB causing jejunal obstruction. RESULT: Endoscopic removal of an eroded ABG causing bowel obstruction was successful. CONCLUSION: Endoscopy remains a safe and relatively non-invasive approach to deal with such complications.

Decreasing complication rates for one-stage conversion band to laparoscopic sleeve gastrectomy: A retrospective cohort study.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) revision surgery is often necessary because of its high failure rate. The objective of this study was to demonstrate that better patient selection, when converting a failed LAGB to a laparoscopic sleeve gastrectomy (LSG) as a one-stage revision procedure, is safe, feasible and improves the complication rate. PATIENTS AND METHODS: A retrospective chart review was performed on patients who underwent a one-stage conversion of failed gastric banding to a LSG. Collected data included age, sex, body mass index (BMI), intraoperative complications, length of stay and post-operative complications. The results were compared to a previous study of 90 cases of LSG as a revision procedure for failed LAGB. RESULTS: There were 75 patients in the current study, 61 women and 14 men, aged 25-67 (average: 46), with a mean BMI of 45 kg/m2 (32-66). Seventy patients (93.3%) were operated for insufficient weight loss and 5 patients (6.7%) for intolerance to the band. In our previous study, 35 patients (39%) were operated for slippage, erosion or obstruction and 14 (15.6%) had post-operative complications as opposed to only 4 patients (5.3%) in this series (P = 0.0359). Gastric leak also improved to 1.3% compared to 5.5% previously. Average hospitalisation time was 2.5 days (1-40). CONCLUSIONS: Rigorous patient selection, without band complications such as slippage, erosion or obstruction, allows for a significantly lower rate of operative complications for a one-stage conversion of failed gastric banding to a LSG.

Efficiency of Laparoscopic One-Step Revision of Failed Adjusted Gastric Banding to Gastric Sleeve: a Retrospective Review of 101 Consecutive Patients.

BACKGROUND: Until recently, laparoscopic adjustable gastric banding (LAGB) was one of the most commonly performed bariatric surgeries worldwide. Today, its high rate of complications and failure rates up to 70% requires revisional surgery. The one-stage conversion from LAGB to laparoscopic sleeve gastrectomy (LSG) has been shown to be safe, although there are some concerns on efficacy and long-term weight loss. OBJECTIVES: To demonstrate that one-step revision of LAGB to another restrictive procedure, such as LSG, might have efficient long-term outcomes. METHODS: The charts from 133 revisional LSGs for failed or complicated LAGB were retrospectively reviewed for the period between January 2010 and August 2017. Thirty-two patients were excluded for loss to follow-up. Demographics, complications, and percentage of excess weight loss (%EWL) were determined. RESULTS: One hundred one patients were included (85 women and 16 men), with a mean age of 48.5 years, and a mean body mass index of 47.1 kg/m2. During the follow-up, 15 patients (15%) underwent a second revisional surgery for weight loss failure (8 Roux-en-Y gastric bypass (RYGBP), 3 biliopancreatic diversion, 3 single anastomosis duodenal-ileal bypass, 1 revisional LSG). Ten patients (10%) had long-term complications (8 severe reflux and 2 stenosis) during this period and underwent a second revisional surgery (10 RYGBP). The remaining 76 had a mean follow-up of 4.3 years and a mean %EWL of 53.2%. CONCLUSION: Single-stage conversion to LSG is a safe and appropriate solution for failed or complicated LAGB with good long-term weight loss.

Laparoscopic Sleeve Gastrectomy: A Radiological Guide to Common Postsurgical Failure.

Laparoscopic sleeve gastrectomy is one of the most common bariatric procedures worldwide. It has recently gained in popularity because of a low complication rate, satisfactory resolution of comorbidities, and excellent weight loss outcome. This article reviews the surgical technique, expected postsurgical imaging appearance, and imaging findings of common complications after laparoscopic sleeve gastrectomy. Understanding of the surgical technique of laparoscopic sleeve gastrectomy and of the normal postsurgical anatomy allows accurate interpretation of imaging findings in cases of insufficient weight loss, weight regain, and postsurgical complications.

Laparoscopic revision of Billroth II with Braun anastomosis into Roux-en-Y anatomy in a patient with intestinal malrotation.

INTRODUCTION: Various reconstructions of the gastro-intestinal tract have been described in the past after distal gastrectomy. Among these, a Billroth II (BII) anastomosis can be performed with the addition of the Omega entero-enterostomy that may theoretically reduce the alkaline reflux. Given the significant complications associated with this procedure such as biliary reflux, marginal ulceration, and afferent loop syndrome, a revision into a Roux-en-Y anatomy is generally recommended. METHODS AND PROCEDURES: A 73-year-old healthy male was referred to our foregut surgery service for treatment of severe biliary gastritis. The patient previously underwent an open distal gastrectomy with a BII reconstruction followed by a Braun-type entero-enterostomy 6 months later. His main complaint was worsening daily biliary reflux with constant regurgitations, which were non-responsive to medical treatment. The preoperative endoscopy confirmed the diagnosis of severe biliary gastritis secondary to alkaline reflux. The distance between the gastro-jejunostomy and the Braun anastomosis was also measured with a pediatric colonoscope and the length of the efferent limb was estimated to be 80 cm. RESULTS: Identification of the afferent and efferent limb was complicated by the patient's incomplete intestinal malrotation with the angle of Treitz being present in the right hypochondrium. Intra-operative gastroscopy enabled visualization of the jejuno-jejunostomy and ensured correct interpretation of the anatomy. Subsequently, resection of the afferent limb completed the revision into a Roux-en-Y anatomy. The patient recovered well after the surgery and was discharged home on post-operative day 2. At 6 months follow-up, the patient's reflux symptoms have completely disappeared. CONCLUSION: BII reconstruction with or without Braun entero-enterostomy is a classic historical option following distal gastrectomy. Surgical revision of a BII into a Roux-en-Y anatomy is a good solution for severe biliary reflux and other long-term complications. Intra-operative endoscopy is a great adjunct to laparoscopic exploration in case of complex surgical procedures.

Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric surgery worldwide. Gastric sleeve stenosis is the most common postoperative complication, occurring in up to 3.9% of the cases. Current treatment options include endoscopic treatments, such as dilatations and stent placement as well as surgical revisions such as laparoscopic Roux-en-Y gastric bypass (LRYGB), wedge gastrectomy or seromyotomy. METHODS: A retrospective analysis of our prospectively collected therapeutical endoscopy database was performed between January 2014 and February 2017. We included all cases of axial deviation or stenosis post LSG, which were treated endoscopically. Patients with concomitant sleeve leaks were excluded. Endoscopic interventions were performed under general anaesthesia and fluoroscopic assistance when needed. Sequential treatment with CRE balloons, achalasia balloons (30-40 mm) and fully covered stent placement for refractory cases was performed. RESULTS: A total of 1332 LSG were performed. Overall, 27/1332 patients (2%) developed a gastric stenosis. All patients presented an axial deviation at the incisura angularis and 26% had a concomitant proximal stenosis. Successful endoscopic treatments were performed in 56% (15/27) of patients, 73% of the successful patients underwent a single dilatation procedure. All successful cases had a maximum of 3 interventions. The unsuccessful cases (44%) underwent LRYGB. Mean time between the primary surgery and the diagnosis of the stenosis was 10.3 months. Mean follow-up after the endoscopic treatment was 11.5 months. A stent migration was the only complication (3.7%) recorded. CONCLUSIONS: Endoscopic treatment appears to be effective in 56% of patients with post-LSG stenosis. Only one session of achalasia balloon dilatation is necessary in 73% of successful cases. Pneumatic balloon dilatation seems to be a safe procedure in this patient population. Surgical revision into a LRYGB offers good outcomes in patients that have failed three consecutive endoscopic treatments.

Sleep, chronic pain, and opioid risk for apnea.

Pain is an unwelcome sleep partner. Pain tends to erode sleep quality and alter the sleep restorative process in vulnerable patients. It can contribute to next-day sleepiness and fatigue, affecting cognitive function. Chronic pain and the use of opioid medications can also complicate the management of sleep disorders such as insomnia (difficulty falling and/or staying asleep) and sleep-disordered breathing (sleep apnea). Sleep problems can be related to various types of pain, including sleep headache (hypnic headache, cluster headache, migraine) and morning headache (transient tension type secondary to sleep apnea or to sleep bruxism or tooth grinding) as well as periodic limb movements (leg and arm dysesthesia with pain). Pain and sleep management strategies should be personalized to reflect the patient's history and ongoing complaints. Understanding the pain-sleep interaction requires assessments of: i) sleep quality, ii) potential contributions to fatigue, mood, and/or wake time functioning; iii) potential concomitant sleep-disordered breathing (SDB); and more importantly; iv) opioid use, as central apnea may occur in at-risk patients. Treatments include sleep hygiene advice, cognitive behavioral therapy, physical therapy, breathing devices (continuous positive airway pressure - CPAP, or oral appliance) and medications (sleep facilitators, e.g., zolpidem; or antidepressants, e.g., trazodone, duloxetine, or neuroleptics, e.g., pregabalin). In the presence of opioid-exacerbated SDB, if the dose cannot be reduced and normal breathing restored, servo-ventilation is a promising avenue that nevertheless requires close medical supervision.

Does Sleep Bruxism Contribute to Headache-Related Disability After Mild Traumatic Brain Injury? A Case-Control Study.

AIMS: To explore whether traumatic brain injury (TBI) patients have a higher prevalence of sleep bruxism (SB) and a higher level of orofacial muscle activity than healthy controls and whether orofacial muscle activity in the context of mild TBI (mTBI) increases the risk for headache disability. METHODS: Sleep laboratory recordings of 24 mTBI patients (15 males, 9 females; mean age ± standard deviation [SD]: 38 ± 11 years) and 20 healthy controls (8 males, 12 females; 31 ± 9 years) were analyzed. The primary variables included degree of headache disability, rhythmic masticatory muscle activity (RMMA) index (as a biomarker of SB), and masseter and mentalis muscle activity during quiet sleep periods. RESULTS: A significantly higher prevalence of moderate to severe headache disability was observed in mTBI patients than in controls (50% vs 5%; P = .001). Although 50% and 25% of mTBI patients had a respective RMMA index of ≥ 2 episodes/hour and ≥ 4 episodes/hour, they did not present more evidence of SB than controls. No between-group differences were found in the amplitude of RMMA or muscle tone. Logistic regression analyses suggested that while mTBI is a strong predictor of moderate to severe headache disability, RMMA frequency is a modest but significant mediator of moderate to severe headache disability in both groups (odds ratios = 21 and 2, respectively). CONCLUSION: Clinicians caring for mTBI patients with poorly controlled headaches should screen for SB, as it may contribute to their condition.

Individuals with pain need more sleep in the early stage of mild traumatic brain injury.

OBJECTIVE: Hypersomnia is frequently reported after mild traumatic brain injury (mTBI), but its cause(s) remain elusive. This study examined sleep/wake activity after mTBI and its association with pain, a comorbidity often associated with insomnia. METHODS: Actigraphy recording was performed for 7 ± 2 consecutive days in 56 individuals at one month post-mTBI (64% male; 38 ± 12 years), 24 individuals at one year post-mTBI (58% male; 44 ± 11years), and in 20 controls (50% male; 37 ± 12 years). Pain intensity and its effect on quality of life was assessed with a visual analogue scale and the Short Form Health Survey (SF-36) bodily pain subscale. RESULTS: Overall, few differences in sleep/wake patterns were found between mTBI patients and controls. However, higher percentages of mTBI individuals with moderate-to-severe pain were found to require more than eight hours of sleep per day (37% vs11%; p = 0.04) and to be frequent nappers (defined as those who took three or more naps per week) (42% vs 22%; p = 0.04) compared to those with mild or no pain at one month postinjury. Correcting for age and depression, The SF-36 score was found to be a significant predictor of sleep duration exceeding eight hours per day at one month (odds ratio = 0.95; 95% confidence interval = 0.92-0.99; p = 0.01), but not at one year post-mTBI. Pain and increased sleep need (in terms of hours per day or napping frequency) were found to co-exist in as much as 29% of mTBI patients at one month postinjury. CONCLUSION: Pain could be associated with more pronounced sleep need in about one-third of mTBI patients during early recovery. Unalleviated pain, found in more than 60% of mTBI patients, should therefore be looked for in all mTBI patients reporting new onset of sleep disorder, not only in those with insomnia.

Evolution of endoscopic treatment of sleeve gastrectomy leaks: from partially covered to long, fully covered stents.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) has become a widely accepted option in the treatment of morbid obesity. Gastric leaks after SG occur in .9%-2.2% of the patients, mostly at the gastroesophageal junction. The current treatment algorithm includes drainage, antibiotics, nutritional support, and endoluminal control. OBJECTIVES: Our hypothesis is that long, fully covered stents represent a safe, effective solution for SG leaks. SETTING: University hospital. METHODS: A retrospective analysis of our prospectively collected bariatric database was performed between June 2014 and May 2016. We included all patients treated for leaks after SG. Endoscopic treatment included partially covered metallic stent (Wallstent, Boston Scientific, Galway, Ireland), fully covered stent (Mega stent, Taewoong Medical Industries, Gyeonggi-do, South Korea), over-the-scope clip (Ovesco Endoscopy, Tubingen, Germany), and internal pigtail drainage. RESULTS: A total of 872 SGs were performed. Overall, 10 of 872 patients (1.1%) developed a gastric leak. One patient was an outside referral. The 11 patients underwent endoscopic treatment accompanied by either percutaneous or laparoscopic abscess drainage. Endoscopic fistula closure at the gastroesophageal junction was achieved in 10 of 11 cases and the average time for closure was 9.9 (range: 4-24) weeks. One patient developed a second leak in the antrum, treated by subtotal gastrectomy. Overall, treatment with Wallstent failed in 3 of 5 patients, and these patients were eventually successfully treated with a Mega stent. The initial use of long, fully covered stents was successful in 5 of 6 cases. CONCLUSION: Long, fully covered stents appear to be a good alternative to traditional stents either as primary treatment or after failure of other endoscopic treatments.

Post-concussion symptoms and chronic pain after mild traumatic brain injury are modulated by multiple locus effect in the BDNF gene through the expression of antisense: A pilot prospective control study.

Background: Mild traumatic brain injury (mTBI) often results in post-concussion symptoms, chronic pain, and sleepiness. Genetic factors are thought to play an important role in poor prognosis. Aims: The aims of this study are to (1) document the prevalence of pain and post-concussion symptoms in mTBI patients in acute and chronic phases (2) determine whether candidate genes predispose to post-concussive symptoms and pain. Methods: Posttraumatic symptoms, evaluated using the Rivermead Post-Concussion Symptoms Questionnaire, and pain were assessed in 94 mTBI patients in the acute phase as well as in 22 healthy controls. Assessment was repeated in 36 patients after one year who agreed to participate in the follow-up visit. Gene polymorphisms and expression were assessed in mTBI patients and healthy controls. Results: In the acute phase, mTBI patients with pain (69%) presented more psychological symptoms and sleepiness and were less able to return to work than those without pain. At one year, 19% of mTBI patients had persistent pain and psychological distress. Two haplotypes (H2 and H3) in the brain-derived neurotrophic factor (BDNF) gene were shown to be respectively deleterious and protective against post-concussion symptoms and pain in both acute and chronic phases. Protective haplotype H3 was associated with a decreased expression of the anti-sense of BDNF (BDNF-AS). Deleterious haplotype H2 predicted the development of chronic pain at one year, whereas H3 was protective. Conclusions: This pilot study suggests a protective mechanism of a multilocus effect in BDNF, through BDNF-AS, against post-concussion symptoms and pain in the acute phase and possibly chronic pain at one year post-mTBI. The role of antisense RNA should be validated in larger cohorts.

Contexte: Le traumatisme cranio-cérébral léger (TCCL) donne souvent lieu à des symptômes post-commotionnels, de la douleur chronique et de la somnolence. On croit que des facteurs génétiques jouent un rôle important dans le pronostic défavorable.Buts: Les buts de cette étude sont : 1) documenter la prévalence de la douleur et des symptômes post-commotionnels chez les patients ayant subi un TCCL, au cours des phases aigue et chronique; ii) déterminer si des gènes du candidat le prédisposent à la douleur et aux symptômes post-commotionnels.Méthodes: La douleur et les symptômes post-traumatiques, évalués à l'aide du questionnaire Rivermead sur les symptômes post-commotionnels, ont été évalués chez 94 patients ayant subi un TCCL au cours de la phase aigue, ainsi que chez 22 sujets témoins. Après un an, 36 patients qui avaient accepté de participer à une visite de suivi ont à nouveau été évalués. Les polymorphismes et l'expression des gènes ont été évalués chez les patients ayant subi un TCCL et chez les sujets témoins.Résultats: Au cours de la phase aigue, les patients ayant subi un TCCL avec douleur (69 %) présentaient davantage de symptômes psychologiques et de somnolence et étaient moins aptes à retourner au travail que les patients sans douleur. Après un an, 19 % des patients ayant subi un TCCL souffraient d'une douleur persistante et de détresse psychologique. Deux haplotypes (H2 et H3) dans le gène BDNF se sont montrés respectivement délétère et protecteur contre les symptômes post-commotionnels et contre la douleur, tant au cours de la phase aigue que de la phase chronique. Le haplotype protecteur H3 a été associé à une diminution de l'expression de l'anti-sens de BDNF (BDNF-AS). Le haplotype délétère H2 a prédit le développement de la douleur chronique un an plus tard, tandis que H3 a été protecteur.Conclusions: Cette étude pilote suggère l'existence d'un mécanisme protecteur d'un effet multilocus dans BDNF à travers BDNF-AS, contre les symptômes post-commotionnels et la douleur au cours de la phase aigue et possiblement au cours de la phase chronique, un an après le TCCL. Le rôle de la RNA anti-sens devrait être validé avec de plus grandes cohortes.

Long-term outcome after laparoscopic sleeve gastrectomy in patients over 65 years old: a retrospective analysis.

BACKGROUND: Bariatric surgery has been proven to be a safe and effective treatment for obesity with BMI (body mass index) reduction, and resolution or lowering of obesity-related co-morbidities. The relative age limit for bariatric surgery has gradually been increased to 60 years of age and above. OBJECTIVES: The aim of this study was to assess the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) performed in older patients (≥65 years old). SETTING: University hospital. METHODS: Between May 1, 2007 and November 30, 2013, 30 consecutive patients≥65 years old were included in this retrospective study of our prospectively collected bariatric database. RESULTS: A total of 27 (90%) primary LSG and 3 revisional LSG (10%) were performed. Mean patient age was 67.2 (range: 65-74) years, and mean preoperative BMI (±standard deviation [SD]) was 44.1±5.6 kg/m2. Thirty-day morbidity included 3 cases of self-limiting nausea and vomiting and 1 case of gastric sleeve stenosis necessitating conversion to gastric bypass. No mortality reported. The overall mean percentage of excess weight loss (±SD) and percentage of total weight loss (±SD) at 12 months were 53.8±19.8 and 23.9±8.4; 52.9±21.8 and 24±9.9 at 36 months, respectively. No patients were lost to follow-up but 5 were excluded because they underwent revisions. Age-adjusted mixed model analyses revealed that baseline BMI (P = .018), BMI>45 kg/m2 (P = .001), and having diabetes (P = .030) were associated with excess weight loss<50% across follow-up. CONCLUSION: LSG seems to be effective and safe for patients≥65 years old. Obesity related co-morbidities have improved across follow-up. BMI>45 kg/m2 and diabetes is associated with insufficient weight loss or weight regain.

Medium Increased Risk for Central Sleep Apnea but Not Obstructive Sleep Apnea in Long-Term Opioid Users: A Systematic Review and Meta-Analysis.

STUDY OBJECTIVE: Opioids are associated with higher risk for ataxic breathing and sleep apnea. We conducted a systematic literature review and meta-analysis to assess the influence of long-term opioid use on the apnea-hypopnea and central apnea indices (AHI and CAI, respectively). METHODS: A systematic review protocol (Cochrane Handbook guidelines) was developed for the search and analysis. We searched Embase, Medline, ACP Journal Club, and Cochrane Database up to November 2014 for three topics: (1) narcotics, (2) sleep apnea, and (3) apnea-hypopnea index. The outcome of interest was the variation in AHI and CAI in opioid users versus non-users. Two reviewers performed the data search and extraction, and disagreements were resolved by discussion. Results were combined by standardized mean difference using a random effect model, and heterogeneity was tested by χ(2) and presented as I(2) statistics. RESULTS: Seven studies met the inclusion criteria, for a total of 803 patients with obstructive sleep apnea (OSA). We compared 2 outcomes: AHI (320 opioid users and 483 non-users) and 790 patients with CAI (315 opioid users and 475 non-users). The absolute effect size for opioid use was a small increased in apnea measured by AHI = 0.25 (95% CI: 0.02-0.49) and a medium for CAI = 0.45 (95% CI: 0.27-0.63). Effect consistency across studies was calculated, showing moderate heterogeneity at I(2) = 59% and 29% for AHI and CAI, respectively. CONCLUSIONS: The meta-analysis results suggest that long-term opioid use in OSA patients has a medium effect on central sleep apnea.