Idiopathic intracranial hypertension and bariatric surgery: a systematic review

Background: Idiopathic intracranial hypertension (IIH) is a rare condition typically affecting women with obesity who are of child-bearing age. Patients commonly present with headaches, visual disturbances, pulsatile tinnitus and papilledema. The association between IIH and obesity has been well established in the literature, suggesting that weight loss may contribute to improving IIH. For patients with severe obesity for whom conservative management is not successful, bariatric surgery is an effective modality for weight loss. We aimed to systematically review the literature to determine the efficacy of bariatric surgery in the treatment of IIH Methods: We conducted a comprehensive search of MEDLINE, Embase, Scopus, the Cochrane Library and Web of Science (limited to studies in humans published in English between January 1946 and July 2015). Results: Twelve primary studies (n = 39 patients) were included in the systematic review. All patients had a preoperative diagnosis of IIH. Preoperative body mass index (BMI) was 47.4 ± 3.6 kg/m2 ; BMI improved to 33.7 ± 2.1 kg/m2 and 33.9 ± 11.6 kg/m2 at 6 and 12 months postoperatively, respectively. Lumbar puncture opening pressures decreased from 34.4 ± 6.9 cmH2O to 14.0 ± 3.6 cmH2O after surgery. Common symptoms of IIH improved after bariatric surgery: headaches (100% preoperatively v. 10% postoperatively), visual complaints (62% v. 44%), tinnitus (56% v. 3%) and papilledema (62% v. 8%). Conclusion: Bariatric surgery appears to lead to considerable improvement in IIH. Idiopathic intracranial hypertension is not a well-publicized comorbidity of obesity, but its presence may be considered as an indication for bariatric surgery.

Contexte: L'hypertension intracrânienne (HTIC) idiopathique est une affection rare qui touche surtout les femmes atteintes d'obésité en âge de procréer. Les symptômes courants sont des maux de tête, des troubles de la vue, des acouphènes pulsatiles et un oedème papillaire. Le lien entre l'HTIC idiopathique et l'obésité est bien établi dans la littérature, ce qui suggère que la perte de poids pourrait améliorer le tableau clinique de l'HTIC. Pour les patients atteints d'obésité sévère pour lesquels le traitement conservateur ne fonctionne pas, la chirurgie bariatrique est un moyen efficace de perdre du poids. Cette revue systématique de la littérature vise à déterminer l'efficacité de la chirurgie bariatrique dans le traitement de l'HTIC idiopathique. Méthodes: Nous avons interrogé MEDLINE, Embase, Scopus, la Bibliothèque Cochrane et Web of Science (limites : études portant sur les humains publiées en anglais entre janvier 1946 et juillet 2015). Résultats: Douze études primaires (n = 39 patients) ont été incluses dans la revue systématique. Tous les patients avaient un diagnostic préopératoire d'HTIC idiopathique. L'indice de masse corporelle (IMC) préopératoire était de 47,4 ± 3,6 kg/m2 ; l'IMC est passé à 33,7 ± 2,1 kg/m2 6 mois après l'opération, puis à 33,9 ± 11,6 kg/m2 12 mois après l'opération. Les pressions d'ouverture des ponctions lombaires sont passées de 34,4 ± 6,9 cmH2O à 14,0 ± 3,6 cmH2O après l'opération. Les symptômes courants de l'HTIC idiopathique se sont améliorés après la chirurgie bariatrique : maux de tête (100% avant opération c. 10% après), troubles de la vue (62% c. 44%), acouphènes pulsatiles (56% c. 3%) et œdème papillaire (62% c. 8%). Conclusion: La chirurgie bariatrique semble améliorer considérablement les symptômes d'HTIC idiopathique. Cette affection n'est pas une comorbidité bien connue de l'obésité, mais sa présence peut être une indication pour la chirurgie bariatrique comme traitement.

Predictive factors for diabetes remission after bariatric surgery

Background: Bariatric surgery has been shown to induce type 2 diabetes mellitus (T2DM) remission in severely obese patients. After laparoscopic Roux-en-Y gastric bypass (LRYGB), diabetes remission occurs early and independently of weight loss. Previous research has identified preoperative factors for remission, such as duration of diabetes and HbA1c. Understanding factors that predict diabetes remission can help to select patients who will benefit most from bariatric surgery. Methods: We retrospectively reviewed all T2DM patients who underwent laparoscopic sleeve gastrectomy (LSG) or LRYGB between January 2008 and July 2014. The primary outcome was diabetes remission, defined as the absence of hypoglycemic medications, fasting blood glucose < 7.0 mmol/L and HbA1c < 6.5%. Data were analyzed using multivariable logistic regression analysis to identify predictive factors of diabetes remission. Results: We included 207 patients in this analysis; 84 (40.6%) had LSG and 123 (59.4%) had LRYGB. Half of the patients (49.8%) achieved diabetes remission at 1 year. Multivariable logistic analysis showed that LRYGB had higher odds of diabetes remission than LSG (odds ratio [OR] 6.58, 95% confidence interval [CI] 2.79­15.50, p < 0.001). Shorter duration of diabetes (OR 0.91, 95% CI 0.83­0.99, p = 0.032) and the absence of long-acting insulin (OR 0.0011, 95% CI < 0.000­0.236, p = 0.013) predicted remission. Conclusion: Type of bariatric procedure (LRYGB v. LSG), shorter duration of diabetes and the absence of long-acting insulin were independent predictors of diabetes remission after bariatric surgery.

Contexte: Il a été démontré que la chirurgie bariatrique provoque une rémission du diabète de type 2 chez les patients gravement obèses. Après la dérivation gastrique Roux-en-Y (DGRY) par laparoscopie, la rémission du diabète se produit tôt et indépendamment de la perte de poids. Des recherches antérieures ont identifié des facteurs préopératoires de rémission, notamment la durée du diabète et l'HbA1c. Comprendre les facteurs prédictifs de la rémission du diabète peut aider à sélectionner les patients qui bénéficieront le plus de la chirurgie bariatrique. Méthodes: Nous avons examiné rétrospectivement les dossiers de tous les patients atteints de diabète de type 2 qui ont subi par laparoscopie une gastrectomie en manchon (GM) ou une DGRY entre janvier 2008 et juillet 2014. Le principal résultat a été la rémission du diabète, définie comme l'absence de médicaments hypoglycémiques, la glycémie à jeun < 7,0 mmol/L et l'HbA1c < 6,5 %. Les données ont été soumises à une analyse de régression logistique multiple pour déterminer les facteurs prédictifs de la rémission du diabète. Résultats: Nous avons inclus 207 patients dans cette analyse; 84 (40,6 %) ont subi une GM et 123 (59,4 %), une DGRY. La moitié des patients (49,8 %) ont obtenu une rémission du diabète à 1 an. L'analyse logistique multiple a montré que la DGRY s'accompagnait de probabilités plus élevées de rémission du diabète que la GM (rapport de cotes [RC] 6,58; intervalle de confiance [IC] de 95 %, 2,79­15,50, p < 0,001). La durée plus courte du diabète (RC 0,91; IC de 95 %, 0,83­0,99, p = 0,032) et absence d'insuline à action prolongée (RC 0,0011; IC de 95 % < 0,000­0,236, p = 0,013) étaient prédicteurs de rémission. Conclusion: Le type d'intervention bariatrique (DGRY c. MG), la durée plus courte du diabète et l'absence d'insuline à action prolongée étaient des prédicteurs indépendants de la rémission du diabète après une chirurgie bariatrique.

The fate of laparoscopic adjustable gastric band removal

Background: Long-term complications and lack of weight loss have caused a surge in laparoscopic adjustable gastric band (LAGB) removal. This study reviews the trend of LAGB removal and examines outcomes of patients undergoing subsequent revision bariatric surgery at a single tertiary care centre in Canada. Methods: All LAGB removals performed between January 2008 and December 2016 were reviewed. A subset of patients who underwent revision surgery was then analyzed for patient demographics, weight, body mass index and postoperative complications. Results: During the study period, 211 patients underwent LAGB removal (87.7% female). Most bands were inserted out of province. Reasons for band removal included dysphagia, band slip and weight recidivism. Fifty-nine patients (28%) underwent revision surgery at a mean of 12.8 ± 9.3 (range 0­55) months after LAGB removal. Mean age was 47 ± 9.7 (range 26­63) years, and mean pre-LAGB weight was 131.0 ± 30.0 kg. Following LAGB, the mean weight decreased to 120.5 ± 26.4 kg, but most regained weight after removal to a mean prerevision weight of 125.1 ± 27.0 kg. The lowest mean weight was achieved 12 months after revision surgery (98.7 ± 30.2 kg). The mean percent total weight loss was not significantly different after revision laparoscopic Roux-en-Y gastric bypass compared with revision laparoscopic sleeve gastrectomy (22.8 ± 9.6% v.17.5 ± 6.5%, p = 0.179). The overall revision surgery 30-day complication rate was 18.6% and increased to 23.7% long-term. No deaths occurred. Conclusion: The number of LAGB removals is increasing. Revision bariatric surgery leads to improved weight loss; however, revision surgery is associated with complications.

Contexte: Les complications à long terme et l'absence de perte de poids sont à l'origine de l'augmentation du nombre de retraits d'anneaux gastriques ajustables (AGA) installés par voie laparoscopique. Cette étude se penche sur la tendance aux retraits des AGA et sur les résultats chez les patients qui subissent une chirurgie bari atrique de révision par la suite dans un centre de soins tertiaire au Canada. Méthodes: Tous les retraits d'AGA effectués entre janvier 2008 et décembre 2016 ont été passés en revue. Un sous-groupe de patients ayant subi une chirurgie de révision a ensuite été analysé aux plans des caractéristiques démographiques, de la masse corporelle et des complications postopératoires. Résultats: Pendant la période de l'étude, 211 patients se sont fait retirer leur AGA (87,7 % de femmes). La plupart des anneaux avaient été insérés à l'extérieur de la province. Parmi les raisons invoquées pour les retraits, mentionnons dysphagie, glissement de l'anneau et reprise de poids. Cinquante-neuf patients (28 %) ont subi une chirurgie de révision en moyenne 12,8 ± 9,3 (éventail 0­55) mois après le retrait de l'AGA. L'âge moyen était de 47 ± 9,7 (éventail 26­63) ans et le poids moyen avant l'AGA était de 131,0 ± 30,0 kg. Après l'AGA, le poids moyen a diminué à 120,5 ± 26,4 kg, mais la plupart ont repris du poids après le retrait pour atteindre un poids moyen pré-révision de 125,1 ± 27,0 kg. Le plus bas poids moyen a été atteint 12 mois après la chirurgie de révision (98,7 ± 30,2 kg). La perte de poids totale moyenne en pourcentage n'était pas significativement différente après la dérivation de Roux-en-Y laparoscopique de révision, comparativement à la gastrectomie laparoscopique en manchon de révision (22,8 ± 9,6 % c. 17,5 ± 6,5 %, p = 0,179). Le taux global de complications des révisions chirurgicales à 30 jours a été de 18,6 % et est passé à 23,7 % à plus long terme. Aucun décès n'est survenu. Conclusion: Le nombre de retraits d'AGA est en hausse. La révision de la chirurgie bariatrique a amélioré la perte de poids, mais elle s'accompagne de complications.

Diagnostic evaluation of sentinel lymph node biopsy using indocyanine green and infrared or fluorescent imaging in gastric cancer: a systematic review and meta-analysis.

BACKGROUND: Sentinel node navigation surgery (SNNS) for gastric cancer using infrared visualization of indocyanine green (ICG) is intriguing because it may limit operative morbidity. We are the first to systematically review and perform meta-analysis on the diagnostic utility of ICG and infrared electronic endoscopy (IREE) or near infrared fluorescent imaging (NIFI) for SNNS exclusively in gastric cancer. METHODS: A search of electronic databases MEDLINE, EMBASE, SCOPUS, Web of Science, and the Cochrane Library using search terms "gastric/stomach" AND "tumor/carcinoma/cancer/neoplasm/adenocarcinoma/malignancy" AND "indocyanine green" was completed in May 2017. Articles were selected by two independent reviewers based on the following major inclusion criteria: (1) diagnostic accuracy study design; (2) indocyanine green was injected at tumor site; (3) IREE or NIFI was used for intraoperative visualization. 327 titles or abstracts were screened. The quality of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2. RESULTS: Ten full text studies were selected. 643 patients were identified with the majority of patients possessing T1 tumors (79.8%). Pooled identification rate, diagnostic odds ratio, sensitivity, and specificity were 0.99 (0.97-1.0), 380.0 (68.71-2101), 0.87 (0.80-0.93), and 1.00 (0.99-1.00), respectively. The summary receiver operator characteristic for ICG + IREE/NIFI demonstrated a test accuracy of 98.3%. Subgroup analysis found improved test performance for studies with low-risk QUADAS-2 scores, studies published after 2010 and submucosal ICG injection. IREE had improved diagnostic odds ratio, sensitivity, and identification rate compared to NIFI. Heterogeneity among studies ranged from low (I2 < 25%) to high (I2 > 75%). CONCLUSIONS: We found encouraging results regarding the accuracy, diagnostic odds ratio, and specificity of the test. The sensitivity was not optimal but may be improved by a strict protocol to augment the technique. Given the number and heterogeneity of studies, our results must be viewed with caution.

The role of antibiotics in acute uncomplicated diverticulitis: A systematic review and meta-analysis.

BACKGROUND: Antibiotics use in acute uncomplicated diverticulitis (AUD) remains debated despite recent studies suggesting no difference in outcomes for patients treated without antibiotics. DATA SOURCES: Systematic review and meta-analysis were performed to determine the role of antibiotics in managing AUD. Literature search was conducted using Medline, EMBASE, Scopus, the Cochrane Library, and Web of Science databases from 1946 to June 2017. Eight studies with 2469 patients were included for review. Overall complication rates were not statistically significant between groups (OR 0.72; CI 0.45 to 1.16; P = 0.18), but antibiotic use was associated with a longer length of stay in hospital. Subgroup analysis revealed no difference in readmission rates, treatment failure rates, progression to complicated diverticulitis, or increased need for elective or emergent surgery between study groups. CONCLUSIONS: Antibiotic use in patients with AUD increases length of hospital stay but is not associated with a reduction in overall or individual complication rates.

The utility of routine esophagogastroduodenoscopy before laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: The routine use of esophagogastroduodenoscopy (EGD) before laparoscopic Roux-en-y gastric bypass (LRYGB) is debatable. Various studies have reported high diagnostic yield of routine EGD before LRYGB to detect pathologies that could alter surgical management. However, other studies have found that preoperative EGD did not identify significant pathologies that changed clinical management; therefore, it is not indicated in asymptomatic patients. OBJECTIVES: We aimed to study the utility of routine EGD in patients before LRYGB. SETTING: Academic teaching hospital, (Royal Alexandra Hospital, Canada). METHODS: A retrospective review of patients undergoing LRYGB with 1 surgeon at our hospital from May 2014 to March 2016 was completed. EGD findings were compared with surgical gastrojejunal specimen pathology and postoperative complications. RESULTS: There were 116 patients who underwent EGD before LRYGB with 113 reported EGDs, of which 46.0% were normal, 40.7% had findings that did not result in a change of management, and 13.3% had findings resulting in a change of management. In the gastrojejunal specimen, 16 patients (14.2%) were found to have chronic gastritis. The relative risk of patients having gastrojejunal gastritis was 5.1 (P<.0005) for patients with gastritis on EGD and 5.1 (P<.0005) for patients with Helicobacter pylori infection on EGD. After surgery, 18 patients (15.9%) had complications. Preoperative EGD findings were not associated with postoperative complications. CONCLUSION: Based on the findings from this study, we recommend using less invasive screening in the routine workup of patients awaiting LRYGB and reserving EGD for symptomatic patients.

A comparison of revisional and primary bariatric surgery.

BACKGROUND: Revisional surgery is an important component of addressing weight regain and complications following primary bariatric surgery. Owing to provincial need and the complexity of this patient population, a specialized multidisciplinary revision clinic was developed. We sought to characterize patients who undergo revision surgery and compare their outcomes with primary bariatric surgery clinic data. METHODS: We completed a retrospective chart review of bariatric revision clinic patients compared with primary bariatric surgery patients from December 2009 to June 2014. RESULTS: We reviewed the charts of 2769 primary bariatric clinic patients, 886 of whom had bariatric surgery, and 534 revision bariatric clinic patients, 83 of whom had revision surgery. Fewer revision clinic patients underwent surgery than primary clinic patients (22% v. 32%). The mean preoperative body mass index (BMI) was 44.7 ± 9.5 in revision patients compared with 45.7 ± 7.6 in primary bariatric surgery patients. Most revision patients had a prior vertical banded gastroplasty (VBG; 48%) or a laparoscopic adjustable gastric band (LAGB; 24%). Bands were removed in 36% of all LAGB patients presenting to clinic. Of the 134 procedures performed in the revision clinic, 83 were bariatric weight loss surgeries, and 51 were band removals. Revision clinic patients experienced a significant decrease in BMI (from 44.7 ± 9.5 to 33.8 ± 7.5, p < 0.001); their BMI at 12-month follow-up was similar to that of primary clinic patients (34.5 ± 7.0, p = 0.7). Complications were significantly more frequent in revision patients than primary patients (41% v. 15%, p < 0.001). CONCLUSION: A bariatric revision clinic manages a wide variety of complex patients distinct from those seen in a primary clinic. Operative candidates at the revision clinic are chosen based on favourable medical, anatomic and psychosocial factors, keeping in mind the resource constraints of a public health care system.

CONTEXTE: La chirurgie de révision est une intervention importante lors d'une reprise de poids ou lors de complications à la suite d'une chirurgie bariatrique primaire. Compte tenu des besoins provinciaux et de la complexité de cette population de patients, une clinique de révision multidisciplinaire spécialisée a été créée. Nous avons voulu caractériser les patients qui subissent une chirurgie de révision et comparer leurs résultats aux données de la clinique de chirurgie bariatrique primaire. MÉTHODES: Nous avons procédé à un examen rétrospectif des dossiers des patients de la clinique de révision bariatrique par rapport aux patients ayant subi une chirurgie bariatrique primaire entre décembre 2009 et juin 2014. RÉSULTATS: Nous avons examiné les dossiers de 2769 patients de la clinique bariatrique primaire, dont 886 avaient subi une chirurgie bariatrique, et 534 patients de la clinique de révision, dont 83 avaient subi une chirurgie de révision. Un moins grand nombre de patients de la clinique de révision ont subi une chirurgie comparativement aux patients de la clinique primaire (22 % c. 32 %). L'indice de masse corporelle (IMC) préopératoire moyen était de 44,7 ± 9,5 chez les patients de la clinique de révision, contre 45,7 ± 7,6 chez les patients ayant subi la chirurgie bariatrique primaire. La plupart des patients de la clinique de révision avaient déjà subi une gastroplastie verticale (48 %) ou une pose d'anneau gastrique ajustable par voie laparoscopique (24 %). Les anneaux gastriques ont été retirés chez 36 % de tous les patients de ce dernier groupe s'étant présentés à la clinique. Parmi les 134 interventions effectuées à la clinique de révision, 83 étaient des chirurgies bariatriques (pour perte de poids) et 51 concernaient des retraits d'anneaux. Les patients de la clinique de révision ont obtenu une diminution significative de leur IMC (de 44,7 ± 9,5 à 33,8 ± 7,5, p < 0,001), qui, au moment du suivi après 12 mois, était semblable à celui des patients de la clinique primaire (34,5 ± 7,0, p = 0,7). Les complications ont été considérablement plus fréquentes chez les patients soumis à une chirurgie de révision que chez les patients soumis à une chirurgie primaire (41 % c. 15 %, p < 0,001). CONCLUSION: Une clinique de révision bariatrique gère une grande diversité de patients complexes, qui sont différents de la population suivie dans une clinique d'intervention primaire. À la clinique de révision, les candidats à l'opération sont choisis en fonction de facteurs médicaux, anatomiques et psychosociaux favorables, en gardant à l'esprit les ressources limitées du système de santé public.

Revision of sleeve gastrectomy to Roux-en-Y Gastric Bypass: A Canadian experience.

INTRODUCTION: Sleeve gastrectomy (SG) can be associated with inadequate weight loss, insufficient resolution of co-morbidities and severe reflux. Conversion to Roux-en-Y Gastric Bypass (RYGB) is a potential solution. The aim of this study was to determine the common indications for conversion from SG to RYGB at our centre, and evaluate patient outcomes with respect to weight loss and co-morbidity resolution. METHODS: A retrospective review of patients who underwent conversion from SG to RYGB between 2008 and 2015. RESULTS: 273 SGs were performed of which 6.6% (n = 18) were converted to RYGB most commonly due to inadequate weight loss (65.3%) and severe reflux (26.1%). Two patients were converted as a planned two-stage approach to RYGB. Patients went from a mean preoperative BMI of 50.5 to a mean BMI of 40.5 post-SG on average by 20.9 months. The mean time to conversion was 41.8 months. There was a positive correlation between pre-SG BMI and time to conversion (p = 0.040). The mean BMI after conversion was 36.4, but this additional weight loss was not significant (p = 0.057). After conversion, four of the five diabetic patients are now medication free and 75% of patients no longer have reflux symptoms. All patients had complete resolution of their hypertension and obstructive sleep apnea. Revision perioperative complication rates were comparable to primary RYGB. Two patients developed new onset iron deficiency anemia. CONCLUSION: Revision to RYGB is a safe option for SG failure and resulted in significant benefits from co-morbidity resolution.

A population-based study of outcomes in patients with gastrointestinal neuroendocrine tumours.

BACKGROUND: Neuroendocrine tumours (NETs) are heterogeneous, with varying presentations and treatment options. To our knowledge, there are no randomized and few long-term studies of patient outcomes. The role of surgical and medical therapy for local, regional and metastatic disease continues to be evaluated in the literature. METHODS: We conducted a population-based search of the provincial cancer registry to identify patients with gastrointestinal NETs from the stomach, small intestine, colon and rectum diagnosed between 1990 and 2005 and assessed their outcomes. RESULTS: We examined clinicopathological information on the outcomes of 530 patients with gastrointestinal NETs. The overall incidence of NETs increased from 11 per million to 19 per million during the study period. Advancing stage and patient age were associated with poor overall or disease-specific outcomes. Surgery, both curative and palliative, was associated with decreased risk of overall (hazard ratio [HR] 0.5, p < 0.001) and disease-specific (HR 0.5, p < 0.001) death. The biggest benefit was observed in patients with distant disease, in whom 5-year disease-specific survival for R0 resections was nearly double that for patients with macroscopic residual disease (92% v. 48%, p = 0.009). Older age was associated with poor 5-year overall and disease-specific survival (p < 0.001). CONCLUSION: There has been a significant increase in incidence of gastrointestinal NETs, and advancing patient age, but not sex, is linked to poor outcomes in terms of overall and disease-specific survival. Surgery, both curative and palliative, was associated with decreased risk of overall and disease-specific death. Compared with patients with residual macroscopic disease, patients with distant disease were nearly twice as likely to survive 5 years if they had R0 resections. The use of radioisotope therapy and long-acting octreotide therapy was also associated with improved outcomes overall.

CONTEXTE: Les tumeurs neuroendocrines (TNE) sont hétérogènes, et les tableaux et options thérapeutiques sont variables. À notre connaissance, il n'existe pas d'études randomisées et il y a peu d'études à long terme sur les résultats chez les patients. Le rôle du traitement chirurgical et médicamenteux de la maladie locale, régionale et métastatique continue d'être évalué dans la littérature. MÉTHODES: Nous avons procédé à une interrogation démographique du Registre provincial du cancer pour recenser les patients atteints de TNE gastro-intestinales provenant de l'estomac, de l'intestin grêle, du côlon et du rectum, diagnostiqués entre 1990 et 2005 et nous avons évalué les résultats. RÉSULTATS: Nous avons examiné les données clinico-pathologiques des résultats enregistrés chez 530 patients atteints de TNE gastro-intestinales. L'incidence globale des TNE a augmenté de 11 par million à 19 par million pendant la période de l'étude. Le stade de la maladie et l'âge avancés ont été associés à des résultats globaux ou spécifiques à la maladie moins favorables. La chirurgie, curative et palliative, a été associée à un risque moindre de décès global (risque relatif [RR] 0.5, p < 0,001) et spécifique à la maladie (RR 0,5, p < 0,001). L'avantage le plus marqué a été observé chez les patients présentant une maladie distale, chez qui la survie à 5 ans spécifique à la maladie pour les résections R0 était près de 2 fois celle des patients présentant une maladie macroscopique résiduelle (92 % c. 48 %, p = 0,009). L'âge avancé a été associé à une survie à 5 ans globale et spécifique à la maladie défavorable (p < 0,001). CONCLUSION: L'incidence des TNE gastro-intestinales a significativement augmenté, et l'âge avancé des patients, mais non le sexe, est lié à des résultats défavorables aux plans de la survie globale et spécifique à la maladie. La chirurgie, curative et palliative, a été associée à un risque moindre de décès global et spécifique à la maladie. Comparativement aux patients ayant une maladie macroscopique résiduelle, ceux qui avaient une maladie distale étaient près de 2 fois plus susceptibles de survivre 5 ans s'ils avaient des résections R0. Les traitements par radio-isotopes et octréotide à longue durée d'action ont aussi été associés à une amélioration globale des résultats.

LINX® magnetic esophageal sphincter augmentation versus Nissen fundoplication for gastroesophageal reflux disease: a systematic review and meta-analysis.

BACKGROUND: The LINX® magnetic sphincter augmentation system (MSA) is a surgical technique with short-term evidence demonstrating efficacy in the treatment of medically refractory or chronic gastroesophageal reflux disease (GERD). Currently, the Nissen fundoplication is the gold-standard surgical treatment for GERD. We are the first to systematically review the literature and perform a meta-analysis comparing MSA to the Nissen fundoplication. METHODS: A comprehensive search of electronic databases (e.g., MEDLINE, EMBASE, SCOPUS, Web of Science and the Cochrane Library) using search terms "Gastroesophageal reflux or heartburn" and "LINX or endoluminal or magnetic" and "fundoplication or Nissen" was completed. All randomized controlled trials, non-randomized comparison study and case series with greater than 5 patients were included. Five hundred and forty-seven titles were identified through primary search, and 197 titles or abstracts were screened after removing duplicates. Meta-analysis was performed on postoperative quality of life outcomes, procedural efficacy and patient procedural satisfaction. RESULTS: Three primary studies identified a total of 688 patients, of whom 273 and 415 underwent Nissen fundoplication and MSA, respectively. MSA was statistically superior to LNF in preserving patient's ability to belch (95.2 vs 65.9%, p < 0.00001) and ability to emesis (93.5 vs 49.5%, p < 0.0001). There was no statistically significant difference between MSA and LNF in gas/bloating (26.7 vs 53.4%, p = 0.06), postoperative dysphagia (33.9 vs 47.1%, p = 0.43) and proton pump inhibitor (PPI) elimination (81.4 vs 81.5%, p = 0.68). CONCLUSION: Magnetic sphincter augmentation appears to be an effective treatment for GERD with short-term outcomes comparable to the more technically challenging and time-consuming Nissen fundoplication. Long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation.

The Effect of Bariatric Surgery on the Spectrum of Fatty Liver Disease.

Nonalcoholic fatty liver disease is becoming one of the most common causes of liver disease in the western world. The most significant risk factors are obesity and the metabolic syndrome for which bariatric surgery has been shown to be an effective treatment. However, the effects of bariatric surgery on nonalcoholic fatty liver disease, specifically liver fibrosis and cirrhosis, are not well established. We review published bariatric surgery outcomes with respect to nonalcoholic liver disease. On the basis of this review we suggest that bariatric surgery may provide a viable treatment option for the treatment of nonalcoholic fatty liver disease, including patients with fibrosis and compensated cirrhosis, and that this topic should be a target of future investigation.

Intragastric Balloon for Management of Severe Obesity: a Systematic Review.

Older models of intragastric balloons (IGBs) had unacceptably high complication rates and inconsequential weight loss. With FDA approval of newer models, we aimed to systematically examine the literature regarding the efficacy of IGB therapy for obesity. A comprehensive electronic database search was completed. Title searching was restricted to the following keywords: bariatric, gastric, gastric bypass, gastric band, sleeve gastrectomy, and intragastric balloon. Twenty-six primary studies (n = 6101) were included. At balloon removal, mean change in weight and BMI were 15.7 ± 5.3 kg and 5.9 ± 1.0 kg/m(2). The most common complications were nausea/vomiting (23.3 %) and abdominal pain (19.9 %). Serious complications were rare: mortality (0.05 %) and gastric perforation (0.1 %). IGBs are associated with marked short-term weight loss with limited serious complications.

A Systematic Review and Meta-Analysis of Outcomes for Type 1 Diabetes after Bariatric Surgery.

Background. The utility of bariatric surgery in type 1 diabetes remains controversial. The aim of the present study is to evaluate glycemic control outcomes in obese patients with type 1 diabetes after bariatric surgery. Methods. A comprehensive search of electronic databases was completed. Inclusion criteria included human adult subjects with BMI ≥35 kg/m(2) and a confirmed diagnosis of type 1 diabetes who underwent a bariatric surgical procedure. Results. Thirteen primary studies (86 patients) were included. Subjects had a mean age of 41.16 ± 6.76 years with a mean BMI of 42.50 ± 2.65 kg/m(2). There was a marked reduction in BMI postoperatively at 12 months and at study endpoint to 29.55 ± 1.76 kg/m(2) (P < 0.00001) and 30.63 ± 2.09 kg/m(2) (P < 0.00001), respectively. Preoperative weighted mean total daily insulin requirement was 98 ± 26 IU/d, which decreased significantly to 36 ± 15 IU/d (P < 0.00001) and 42 ± 11 IU/d (P < 0.00001) at 12 months and at study endpoint, respectively. An improvement in HbA1c was also seen from 8.46 ± 0.78% preoperatively to 7.95 ± 0.55% (P = 0.01) and 8.13 ± 0.86% (P = 0.03) at 12 months and at study endpoint, respectively. Conclusion. Bariatric surgery in patients with type 1 diabetes leads to significant reductions in BMI and improvements in glycemic control.

Gastric Band Removal in Revisional Bariatric Surgery, One-Step Versus Two-Step: a Systematic Review and Meta-analysis.

We aimed to systematically review the literature comparing the safety of one-step versus two-step revisional bariatric surgery from laparoscopic adjustable gastric banding (LAGB) to Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). There is debate on the safety of removing the gastric band and performing revisional surgery immediately or in a delayed, two-step fashion due to potential higher complications in one-step revisions. A systematic and comprehensive search of the literature was conducted. Included studies directly compared one-step and two-step revisional surgery. Eleven studies were included with 1370 patients. Meta-analysis found comparable rates of complications, morbidity, and mortality between one-step and two-step revisions for both RYGB and SG groups. This suggests that immediate or delayed revisional bariatric surgeries are both safe options for LAGB revisions.

The Impact of Bariatric Surgery on Polycystic Ovary Syndrome: a Systematic Review and Meta-analysis.

Bariatric surgery has been proven to be a successful management strategy for morbid obesity, but limited studies exist on its effect on polycystic ovary syndrome (PCOS). A comprehensive search of electronic databases was completed. Meta-analysis was performed on PCOS, hirsutism, and menstrual irregularity outcomes following bariatric surgery. Thirteen primary studies involving a total of 2130 female patients were identified. The incidence of PCOS preoperatively was 45.6 %, which significantly decreased to 6.8 % (P < 0.001) and 7.1 % (P < 0.0002) at 12-month follow-up and study endpoint, respectively. The incidences of preoperative menstrual irregularity and hirsutism both significantly decreased at 12-month and at study end follow-up. Bariatric surgery effectively attenuates PCOS and its clinical symptomatology including hirsutism and menstrual irregularity in severely obese women.

Financial costs and patients' perceptions of medical tourism in bariatric surgery.

SUMMARY: Many Canadians pursue surgical treatment for severe obesity outside of their province or country - so-called "medical tourism." We have managed many complications related to this evolving phenomenon. The costs associated with this care seem substantial but have not been previously quantified. We surveyed Alberta general surgeons and postoperative medical tourists to estimate costs of treating complications related to medical tourism in bariatric surgery and to understand patients' motivations for pursuing medical tourism. Our analysis suggests more than $560 000 was spent treating 59 bariatric medical tourists by 25 surgeons between 2012 and 2013. Responses from medical tourists suggest that they believe their surgeries were successful despite some having postoperative complications and lacking support from medical or surgical teams. We believe that the financial cost of treating complications related to medical tourism in Alberta is substantial and impacts existing limited resources.

Quality of Follow-up: Systematic Review of the Research in Bariatric Surgery.

OBJECTIVE: We aim to systematically review the bariatric surgery literature with regards to adequacy of patient follow-up, meeting the McMaster criteria of ≥80% follow-up. BACKGROUND: Loss to follow-up is a major concern and can potentially bias the outcome and interpretation of a study. The quality of follow-up in bariatric surgery is quite variable with recent systematic reviews criticizing the field for its lack of overall follow-up. METHODS: A complete search of PubMed was performed. Literature was restricted to a range of 5 years (2007-2012), English language, and publications listed in PubMed. The McMaster Evidence-based Criteria for High Quality Studies was used to assess the follow-up data adequacy and a logistic meta-regression was performed to identify factors associated with high quality follow-up studies. RESULTS: Ninety-nine published manuscripts were included. For follow-up at study end, only 40/99 (40.4%) of papers had adequate patient follow-up, 42/99 (42.4%) failed to meet the McMaster criteria and 17/99 (17.2%) failed to report any follow-up results. On average, 31% were lost to follow-up at the study's end. Only shorter study duration, and if the study was performed in the US, were associated with studies meeting the McMaster criteria. CONCLUSIONS: Only 40% of studies in the bariatric surgery literature meet criteria for adequate follow-up. On average, studies have 30% of patients lost to follow-up at the stated end-point. Identified study characteristics associated with high quality follow-up included shorter study duration and studies performed in the US.

Roux-en-Y Gastric Bypass in the Elderly: a Systematic Review.

The prevalence of severe obesity in the elderly is increasing. This systematic review reviews the literature in reference to the efficacy and safety of bariatric surgery on the elderly patient ≥ 65 years. A comprehensive search of electronic databases was completed. The data was limited to include only Roux-en-Y gastric bypass patients ≥ 65 years. Eight primary studies (1835 patients) were included, all case series. Mean age was 67.6 years. Mean excess weight loss at study endpoint was 66.2 %. Mean 30-day mortality was 0.14 %. The mean total post-operative complication rate was 21.1 %, with wound infections being the most common (7.58 %) followed by cardiorespiratory complications (2.96 %). Bariatric surgery is effective in producing marked weight loss in patients ≥ 65 years with an acceptable safety profile.

Endoscopy services and training: a national survey of general surgeons.

BACKGROUND: Delivering high-quality endoscopy services depends largely on the competence of endoscopists. General surgery residency training in endoscopy and the associated quality of endoscopy services being delivered by general surgeons have been the subject of considerable controversy. In conjunction with the Canadian Association of General Surgeons (CAGS) executive board, we formulated a survey to evaluate the general state of endoscopy practice and training among general surgeons in Canada. METHODS: The study was designed as a cross-sectional survey. General surgeons who are members of CAGS were selected to participate in the study and were emailed a link to the online questionnaire regarding the importance of endoscopy. They were asked to compare their training to resident training today. RESULTS: Sixty-nine surveys were completed. The majority of general surgeons (95.7%) indicated that endoscopy was an important skill to possess, and more than 85.5% used endoscopy in their own practices. However, nearly half (46.4%) felt that general surgery endoscopy training in Canada is currently inadequate to produce competent endoscopists. The main qualitative themes emerging from the survey were the inadequacy of current postgraduate endoscopy training (37.5%) and the absence of standardization in training (25.0%). CONCLUSION: Endoscopy is considered integral to academic and community general surgeons' practices; however, the adequacy of training seems to be questioned. Postgraduate training in endoscopy needs to be formalized and standardized, with a greater emphasis placed on teaching endoscopy.

CONTEXTE: La qualité des services d'endoscopie est largement tributaire de la compétence des endoscopistes. La formation en endoscopie pendant la résidence en chirurgie générale et la qualité connexe des services d'endoscopie fournis par les chirurgiens généraux font l'objet d'une importante controverse. En collaboration avec le conseil de direction de l'Association canadienne des chirurgiens généraux (ACCG), nous avons produit un sondage pour évaluer l'état global, chez les chirurgiens généraux au Canada, de la pratique et de la formation en matière d'endoscopie. MÉTHODES: L'étude s'est effectuée sous forme de sondage transversal. Des chirurgiens généraux membres de l'ACCG ont été choisis pour participer à l'étude et ont reçu par courriel un lien vers le questionnaire en ligne sur l'importance de l'endoscopie. On leur a demandé de comparer leur formation à celle que reçoivent maintenant les médecins résidents. RÉSULTATS: En tout, 69 questionnaires ont été remplis. Les chirurgiens généraux ont indiqué en majorité (95,7 %) que l'endoscopie constituait une importante technique à maîtriser, et plus de 85,5 % l'utilisent dans leur pratique. Presque la moitié (46,4 %) étaient toutefois d'avis que la formation actuelle en endoscopie en chirurgie générale au Canada ne peut produire des endoscopistes compétents. Les principaux thèmes qualitatifs que dégage le sondage portent sur la déficience de la formation en endoscopie que reçoivent actuellement les résidents (37,5 %) et sur le manque de normalisation de la formation (25,0 %). CONCLUSION: On considère que l'endoscopie fait partie intégrante des pratiques universitaires et communautaires des chirurgiens généraux, mais on semble douter que la formation soit adéquate. Il faut structurer et normaliser la formation en endoscopie que reçoivent les résidents et insister davantage sur son enseignement.