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Background: Laparoscopic cholecystectomy is considered nowadays as the standard management of acute cholecystitis (AC). However, results from multicentric studies in the general surgical community are still lacking.Methods: A prospective multicenter survey of surgical management of AC patients was conducted over a 2-year period in Belgium. Operative features and patients' clinical outcome were recorded. The impact of independent predictive factors on the choice of surgical approach, the risk of conversion, and the occurrence of postoperative complications was studied by multivariate logistic regression analysis.Results: Fifty-three surgeons consecutively and anonymously included 1,089 patients in this prospective study. A primary open approach was chosen in 74 patients (6.8%), whereas a laparoscopic approach was the first option in 1,015 patients (93.2%). Independent predictive factors for a primary open approach were previous history of upper abdominal surgery [odds ratio (OR) 4.13, p < 0.001], patient age greater than 70 years (OR 2.41, p < 0.05), surgeon with more than 10 years' experience (OR 2.08, p = 0.005), and gangrenous cholecystitis (OR 1.71, p < 0.05). In the laparoscopy group, 116 patients (11.4%) required conversion to laparotomy. Overall, 38 patients (3.5%) presented biliary complications and 49 had other local complications (4.5%). Incidence of bile duct injury was 1.2% in the whole series, 2.7% in the open group, and 1.1% in the laparoscopy group. Sixty patients had general complications (5.5%). The overall mortality rate was 0.8%. All patients who died were in poor general condition [American Society of Anesthesiologists (ASA) III or IV].Conclusions: Although laparoscopic cholecystectomy is currently considered as the standard treatment for acute cholecystitis, an open approach is still a valid option in more advanced disease. However, overall mortality and incidence of bile duct injury remain high. [ABSTRACT FROM AUTHOR]

Background: Open exploration and endoscopic sphincterotomy (ES) remain the preferred treatment of common bile duct stones (CBDS). The recent spread of laparoscopy has worsened the dilemna of choosing between surgical and endoscopic treatment of CBDS. The aim of this study was to critically evaluate the results of our preliminary experience with laparoscopic common bile duct exploration (CBDE) for CBDS.Methods: Ninety-two consecutive patients were prospectively submitted to laparoscopic CBDE. Surgical strategy included an initial transcystic approach or laparoscopic choledochotomy. Failure of stone clearance was managed by conversion to open CBDE or by postoperative ES. Electrohydraulic lithotripsy and papillary balloon dilatation were selectively used. Stone clearance was assessed by choledochoscopy and control cholangiography.Results: The overall laparoscopic stone clearance in this series was 84% (transcystic route 63% and choledochotomy 93%). Conversion to laparotomy was mandatory in 12% of the patients because of incomplete stone clearance and in 5% because of intraoperative complications. Postoperative ES was required in 4% of the patients, giving an overall surgical success rate of 96%. When indicated (small and limited number of stones located below the cysticocholedochal junction, with a dilated and patent cystic duct) the transcystic route had the lower success rate, the higher complication rate, and the shorter operative time and postoperative hospital stay. When indicated (accessible and dilated common bile duct over 7 mm), laparoscopic choledochotomy had the higher success rate, the lower complication rate, the longer operative time, and the longer postoperative hospital stay, which is related to associated external biliary drainage. The hospital mortality included two high-risk patients (2%) and the complications rate was 15%.Conclusions: Laparoscopic CBDE is safe in selected patients. A stratified intraoperative surgical strategy is mandatory in deciding between a transcystic route and choledochotomy with specific indications for each approach. When feasible, laparoscopic choledochotomy is more efficient and safe than the transcystic route, but it is associated with a longer postoperative hospital stay, which is due to external biliary drainage. [ABSTRACT FROM AUTHOR]

Cluster analysis is often used to segment a panel of consumers according to their overall liking. In general, all the consumers are assigned to one of the segments even though they do not fit to the pattern of any cluster. Within the clustering of variables around latent variables (CLV) framework, we propose two new approaches to handle this problem. The first approach (“ K + 1” strategy) consists in explicitly identifying an additional cluster which we refer to as “noise cluster”. The second approach (“Sparse LV” strategy) computes the groups’ latent variables of the CLV method with a sparsity constraint. Both strategies were tested on the basis of two real hedonic case studies and compared to the k -means cluster analysis. They made it possible to improve the discrimination between the products within each cluster and yield homogeneous clusters of consumers for a better understanding of the main tendencies of liking. [ABSTRACT FROM AUTHOR]

Background: A multicentric study was performed to evaluate the clinical results after laparoscopic treatment of pancreatic pseudocysts (PP). Methods: We collected the data of 17 patients presenting with PP and operated on by laparoscopy between 1996 and 2001. There were nine men and eight women with a median age of 42 years (range 30–72). In 15 patients the PP developed after acute pancreatitis and the median delay between the acute onset and surgery was 7 months (range: 2–24). In two patients the PP was associated with chronic pancreatitis. All the patients had a single PP with a median diameter of 9 cm (range: 5–20). Results: According to the location of the PP, a cystogastrostomy was performed in 10 patients and a cystojejunostomy in seven patients. The median operative time was 100 min (range: 80–300). Laparoscopic PP surgery was completed successfully in 16 patients and the median size of the cystoenterostomy was 3 cm (range: 2–5). Necrotic debris was present within the PP in 11 patients. The median postoperative hospital stay was 6 days (range: 4–24). No mortality and no immediate morbidity were recorded. However, two patients were readmitted within the first 3 postoperative weeks because of secondary PP infection. The first patient had an early closure of cystogastrostomy and was treated by endoscopic placement of a stent. The second represented with a right retrocolic abscess after cystojejunostomy and was treated by percutaneous drainage. One patient was lost for follow-up 2 months after surgery. The others had regular clinical and radiological controls. With a median follow-up of 12 months (range: 6–36), no recurrence of PP was observed. Conclusions: The laparoscopic treatment of PP was associated with a low postoperative complication rate and an effective permanent result. That approach avoided some difficulties, particularly bleeding that is classically linked with endoscopic internal drainage. [ABSTRACT FROM AUTHOR]

This article, published in the journal Endoscopy, discusses three cases of misdeployment during an EDGI procedure and the successful use of endoscopic salvage techniques to treat them. The misdeployment occurred during the creation of a gastrogastrostomy fistula, with the distal flange migrating into the peritoneal cavity. Two different techniques, "Remove and Replace" and "LAMS in LAMS," were used to address the issue. The authors suggest that the "LAMS in LAMS" technique may be easier and reduce the risk of losing access, but further studies are needed to confirm its effectiveness. [Extracted from the article]

Introduction et buts de l’étude De nombreuses études cliniques ont démontré l’efficacité de la chirurgie bariatrique dans le contrôle du diabète sucré de type 2. L’enjeu est de taille, compte tenu de la constante progression de la prévalence de la maladie et ses conséquences lourdes en termes de morbidité, de mortalité et de coûts pour la santé publique. L’objectif primaire de l’étude est l’évaluation de l’efficacité des différentes techniques de chirurgie bariatrique dans le contrôle de la glycémie chez des patients diabétiques de type 2. L’objectif secondaire est l’analyse des effets de la chirurgie sur les autres comorbidités liées à l’obésité. Matériel et méthodes Nous avons analysé rétrospectivement les dossiers de 96 patients diabétiques de type 2 (le critère d’inclusion étant une HbA1c supérieure ou égale à 6,5 % sans traitement ou supérieure ou égale à 6 % avec traitement) ayant bénéficié d’une intervention bariatrique de type bypass gastrique ( n = 75) ou sleeve gastrectomie ( n = 21) aux cliniques universitaires Saint-Luc et suivis en consultation à 4 ± 1 mois, 10 ± 1,5 mois et 18 ± 2 mois après l’intervention. Les effets de la chirurgie sur le diabète, le poids et les comorbidités ont été évalué par des Anova à mesures répétées à une voie (selon le type d’intervention), suivies de tests t pour échantillons appariés. La rémission du diabète a été définie sur base d’une HbA1c inférieure à 6,5 % en l’absence de traitement médicamenteux. Les facteurs prédictifs de rémission ont été déterminés. Résultats L’âge moyen au moment de l’intervention était de 52 ± 10 ans et 57 % des patients étaient de sexe féminin. Le poids moyen s’élevait à 119 ± 24 kg et l’indice de masse corporelle à 42,8 ± 6,8 kg/m 2 . L’HbA1c moyenne de départ s’élevait à 7,7 ± 1,4 %, pour une durée estimée d’évolution de la maladie à 7 ± 7 ans. Tous les patients ont bénéficié d’un suivi médical à 4 mois, 76 % à 10 mois et 41 % à 18 mois. À 18 mois, 54 % de la population était en rémission du diabète, sans différence d’efficacité entre le bypass et la sleeve ( p = 0,890), avec respectivement 55 % et 52 % de rémission. L’HbA1c diminuait de 1,4 ± 1,2 % à 4 mois et de 0,3 ± 0,7 % entre 4 et 10 mois ( p < 0,001), parallèlement à une diminution du recours aux traitements médicamenteux du diabète. Le jeune âge au moment de l’intervention, une courte durée d’évolution de la maladie, un faible HbA1c, une thérapie modeste avant l’intervention et une perte de poids importante à 4 mois étaient prédictifs de la rémission du diabète. En outre, l’étude met en évidence, parallèlement à la perte de poids, un effet positif sur la tension artérielle, la dyslipidémie et le syndrome d’apnées du sommeil. Globalement, aucune différence d’évolution entre les patients opérés par bypass ou par sleeve ne fut mise en évidence. Conclusion Chez les patients obèses diabétiques de type 2, une rémission du diabète sucré est observée chez au moins 54 % des sujets 18 mois après une intervention bariatrique. La chirurgie diminue significativement les taux d’HbA1c ainsi que le recours aux traitements médicamenteux du diabète. Des investigations ultérieures seront nécessaires pour évaluer la durabilité de ces résultats. [ABSTRACT FROM AUTHOR]

Background: Optimal preoperative treatment before colorectal cancer metastases (CRCM) resection remains unclear. This study evaluated pathological responses (pR) in CRCM resected after chemotherapy alone or combined with angiogenesis or epidermal growth factor receptor (EGFR) inhibitors.Methods: Pathological response was retrospectively evaluated on 264 resected metastases from 99 patients. The proportion of responding metastases after different preoperative treatments was reported and compared. Patient's progression-free survival (PFS) and overall survival (OS) were compared based on pR.Results: The combination of anti-angiogenics with oxaliplatin-based chemotherapy resulted in more pR than when they were combined with irinotecan-based chemotherapy (80% vs 50%; P<0.001). Inversely, the combination of EGFR inhibitors with oxaliplatin-based chemotherapy seemed to induce fewer pR than when they were combined with irinotecan-based treatment (53% vs 72%; P=0.049). Overall survival at 5 years was improved for patients with a pR in all resected metastases compared with those who did not achieve a pR (68.5% vs 32.6%; P=0.023) and this response was the only factor predicting OS in a multivariate analysis.Conclusion: The chemotherapy partner combined with angiogenesis or EGFR inhibitors influenced pR in resected CRCM. In our exploratory analysis anti-angiogenic/oxaliplatin-based regimens and anti-EGFR/irinotecan-based regimens were associated with the highest pR. Prospective randomised trials should be performed to validate these observations. [ABSTRACT FROM AUTHOR]

Objectives:(1) To investigate whether modulation of the cannabinoid type 1 receptor (CB1R) directly regulates the production of adiponectin (ApN) and other adipokines in omental adipose tissue (OAT) of obese subjects, (2) to establish in which cellular fraction of OAT the effects of CB1R blockade take place and (3) to unravel the underlying mechanisms.Subjects and methods:OAT was obtained from 30 obese subjects (body mass index: 40.6±1.3 kg m−2) undergoing abdominal surgery. Primary cultures of explants or of freshly isolated adipocytes or stromal-vascular cells (SVCs) were used.Results:In OAT explants, the CB1R blocker Rimonabant upregulated ApN gene expression. mRNA abundance of omentin that exhibits insulin-sensitizing properties was upregulated as well. Conversely, mRNA levels of two pro-inflammatory cytokines, macrophage inflammatory protein (MIP)-1β and interleukin (IL)-7 were downregulated. We next examined where these effects took place within OAT. CB1R expression was similar in both cellular fractions. In isolated mature adipocytes, blockade of CB1R reproduced the increase of ApN mRNA and the decrease of IL-7 mRNA, while inducing a rise of ApN secretion into the medium. In isolated SVC, gene expression of omentin, which is restricted to this fraction, was augmented, while that of MIP-1β was diminished. Finally, we deciphered the mechanisms leading to ApN regulation by the endocannabinoid system (ES). We first established that ApN regulation was actually mediated by the CB1R: ApN gene expression was upregulated by Rimonabant and downregulated by the CB1R agonist arachidonyl-2-chloroethylamide (ACEA). Upregulation of ApN by Rimonabant was unaltered by inhibiting cAMP production. However, downregulation of ApN by ACEA was fully reversed by an inhibitor of p38 mitogen-activated protein kinase (p38MAPK) and ACEA increased p38MAPK phosphorylation.Conclusions:Blockade of CB1R attenuates the inflammatory state in both cellular fractions of OAT either by increasing ApN and omentin production or by decreasing mRNAs of MIP-1β and IL-7. ApN regulation by the ES partly involves p38MAPK. [ABSTRACT FROM AUTHOR]

A variety of newly developed mesh products have recently become available to use inside the peritoneal cavity. This analysis reports the first clinical data evaluating the experience with the use of Proceed® mesh in laparoscopic ventral hernia repair. During a 6-month period, 114 adult patients underwent a laparoscopic ventral hernia repair using an intra-abdominal placement of a Proceed mesh. The operative procedure was stratified for all centers. Perioperatively, different parameters were evaluated considering the conversion rate to open procedure, complications such as seroma and hematoma, bowel lesions, urinary retention, acute, and chronic pain, mesh infection, and recurrences. The mean age of the patients was 45 years (range 19–84 years). There were no conversions to open repair and no mortality. Complications included 12 seromas/hematomas (four aspirated), chronic discomfort in two patients, and urinary retention in one patient. There have been four recurrences (3.5%), occurring 3, 4, 4, and 15 months after surgery, respectively. The mean follow-up period was 27 months (range 12–38 months). There have been no documented infections of the mesh. This multicentric study documents a favorable experience using large-pore mesh in laparoscopic ventral hernia repair. There were no major complications related to the mesh. Technical advantages considering mesh handling and long-term advantages considering chronic pain might be of interest with the use of this lightweight mesh for minimally invasive ventral hernia repair. [ABSTRACT FROM AUTHOR]

Background: Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment.Methods: A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain.Recommendations: Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen.Conclusions: Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results. [ABSTRACT FROM AUTHOR]

Background: Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or non-operative treatment. Methods: A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain. Recommendations: Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen. Conclusions: Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results. [ABSTRACT FROM AUTHOR]

Background: A series of 100 consecutive patients with perforated peptic ulcer were prospectively evaluated in a multicenter study. The feasibility of the laparoscopic repair was evaluated.Methods: All patients had peritonitis, 20% were in septic shock, and 57% had delayed perforation. Conversion to laparotomy was necessary in eight patients. The morbidity rate was 9% and mortality rate 5%.Results: The mean delay of postoperative gastric aspiration (mean 3.4 days) and resumed food intake (mean 4.4 days) as well as the mean postoperative hospital stay (mean 9.3 days) were comparable to conventional surgery, but postoperative comfort was subjectively increased by laparoscopy and noticed by all laparoscopic surgeons participating in this study.Conclusions: Laparoscopic repair of perforated peptic ulcer proves to be technically feasable and carries an acceptable morbidity and mortality rate, compared with conventional surgery. [ABSTRACT FROM AUTHOR]

Background: A series of 100 consecutive patients with perforated peptic ulcer were prospectively evaluated in a multicenter study. The feasibility of the laparoscopic repair was evaluated. Methods: All patients had peritonitis, 20% were in septic shock, and 57% had delayed perforation. Conversion to laparotomy was necessary in eight patients. The morbidity rate was 9% and mortality rate 5%. Results: The mean delay of postoperative gastric aspiration (mean 3.4 days) and resumed food intake (mean 4.4 days) as well as the mean postoperative hospital stay (mean 9.3 days) were comparable to conventional surgery, but postoperative comfort was subjectively increased by laparoscopy and noticed by all laparoscopic surgeons participating in this study. Conclusions: Laparoscopic repair of perforated peptic ulcer proves to be technically feasable and carries an acceptable morbidity and mortality rate, compared with conventional surgery. [ABSTRACT FROM AUTHOR]