Obesity and type 1 diabetes mellitus management.

Patients with type 1 diabetes mellitus (T1DM) traditionally had a low body mass index and microangiopathic complications were common. The Diabetes Control and Complications Trial, published in 1993, demonstrated that therapy aimed at maintaining HbA1c levels as close to normal as feasible reduced the incidence of microangiopathy. Since then, the use of intensive insulin therapy to optimise metabolic control became generalised, with two main side effects: a higher rate of severe hypoglycaemia and increased weight gain. Approximately 50% of patients with T1DM are currently obese or overweight, which reduces or nullifies the benefits of good metabolic control, and which has other negative consequences; therefore, strategies to achieve weight control in patients with T1DM are necessary. At present, treatment with GLP-1 and SGLT-2 inhibitors has yielded promising short-term results that need to be confirmed in studies with larger numbers of patients and long-term follow-up. It is possible that, in coming years, the applicability of bariatric surgery in obese patients with T1DM will be similar to that of the general population or T2DM.

Emergence and distribution of the ilioinguinal nerve in the inguinal region: applications to the ilioinguinal anaesthetic block (about 100 dissections).

The variations in the emergence and distribution of the ilioinguinal nerve are the cause of the failures of the ilioinguinal block and the difficulties at interpreting the ilioinguinal nerve syndrome. In order to identify its variations and set reliable anatomical landmarks for performing the ilioinguinal block, we dissected 100 inguinal regions of 51 adult corpses. The nerve was absent in seven cases and double in one case. The ilioinguinal nerve emerged from the internal oblique muscle, passing at 1 +/- 0.8 cm of the inguinal ligament and 3.33 +/- 2 cm of the ventral cranial iliac spine. It appeared behind the inguinal ligament and/or the ventral cranial iliac spine in 19 cases and presented a common trunk with the iliohypogastric nerve in 13 cases. In 47 cases, the nerve appeared in the form of a single trunk. Sixteen modes of division and eight types of predominantly anterior scrotal topographic distribution could be noted. These results show the high variability of the emergence and the sensory distribution of the ilioinguinal nerve. They enable us to propose techniques for ilioinguinal block performance using more accurate anatomical landmarks formed by the inguinal ligament and the ventral cranial iliac spine and a better diagnostic approach of ilioinguinal neuropathies.

[The left gastroepiploic artery: a splenic origin but a variable birthplace]. / L'artère gastro-omentale gauche : une origine splénique mais un niveau de naissance variable.

The left gastroepiploic artery (LGEA) is rarely described. The aim of this study is to report the fashion of its origin considering the greatly surgical interest of the short gastric vessels in the spleen-preserving distal pancreatectomy with excision of splenic pedicle. About 79 fresh cadaveric pieces we dissect and opacified the LGEA to specify its origin based on the Pinus's classification. We measured the distances between the origin of the LGEA and the terminal division of the splenic artery, the splenic hilus and the great gastric curvature. The LGEA arise from the splenic artery. Dissection underlines a troncular origin (type I) in 20.25% of cases, a distal origin from an inferior polar branch (type II) in 68.35% of cases and an origin from a common spleno-gastroepiploic trunk (type III) in 11.4% of cases. The three distances measured was respectively of 28.7, 25.3 and 31.4mm. The arteriography revealed respectively for the same types 21.21, 51.51 and 27.28%. The vascular disposition of the type III well illustrates the important role of the LGEA for the vascularization of the inferior pole of the spleen. Although the LGEA arise from a polar splenic lower branch in more half of the cases, it is important to know the frequency of the other modalities of its origin. These anatomical variations vascular are to be considered during spleen-preserving distal pancreatectomy with excision of splenic pedicle as well as for gastric esophagoplasty.

Anatomical basis of neuropathies and damage to the ilioinguinal nerve during repairs of groin hernias. (about 100 dissections).

Surgical access to the inguinal region, notably during hernia repairs, exposes the ilioinguinal nerve to the risk of damage at the origin of the neuralgia. The incidence of these post-operative neuropathies and their medicolegal consequences justify this study about the anatomical variations of the ilioinguinal nerve. With the aim of preventing its damage during repairs of groin hernias and identifying the factors of onset of chronic spontaneous neuropathy of the ilioinguinal nerve, we dissected 100 inguinal regions of 51 fresh adult corpses. The nerve was absent in seven cases and double in one case. Out of the 94 ilioinguinal nerves observed, we analyzed the path in relation to the inguinal ligament and the connections with the walls of the inguinal canal and its content. The ilioinguinal nerve travels along the superficial surface of the internal oblique muscle, passing on average 1.015 cm from the inguinal ligament. In one case, the fibers of the internal oblique muscle spanned it in several places. The nerve was antero-funicular in 78.72% of cases and perforated the fascia of the external oblique in 28.72% of cases. The terminal division took place in the inguinal canal in 86% of cases, with terminal branches that sometimes perforated the fascia of the external oblique. These results enabled us to better understand the etiopathogenic aspects of certain neuropathies of the groin and to propose techniques useful for the protection of the nerve during repairs of groin hernias.

[Anastomotic method of the gastro-omental arterial circle: interest in the transillumination method at the gastric esophagoplasty]. / Le mode anastomotique du cercle arteriel gastro-omental: interet de la transillumination lors d'une oesophagoplastie gastrique.

The gastroomental (gastroepiploic) arterial circle of the stomach is the main vascular axis of the gastroplasty use as esophagus substitute after esophagectomy. The aim of this anatomoangiographic study is to study the anastomosis between the right and left gastroomental arteries and emphasize interest of the transillumination: an ordinary anatomic method use in surgical practice. We use forty five fresh cadaveric stomach of adult for determine the anastomotic fashion of the arterial circle of the great gastric curvature. About three models of gastric esophagoplasty we verify similarity of vascular transillumination results and we compare with the radiographic exploration. The thickness of the gastrocolic ligament in which progress the gastroomental arterial circle can lead astray for macroscopic determination of anastomotic mode. Thus the type I, II, III and IV which are of 60%, 22,2%, 13,3% and 4,4% at macroscopic observation become 64,1%, 15,4%, 15,4% and 5,1% after arteriographic analysis. Even if the submucosal arteriolar network and the rich parietal anastomosis confer at the stomach the best qualities for esophageal replacement, the multifactorial particularity of success in esophagogastroplasty require identification and preservation of the gastroomental arterial circle. The transillumination which facilitate evaluation of this arterial axis is a simple and accessible process which we advocate.