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Bariatric surgery (BS) leads to substantial weight loss accompanied by reversal of several obesity-related co-morbidities and reduced mortality. However, surgery is associated with risks and its nearly irreversible characteristic requires a clearly established pre- and postoperative clinical pathway. In France, this pathway relies on recommendations made by the High Authority of Health (Haute Autorité de santé (HAS)) in 2009; an update is awaited in 2023. BS should be proposed only after failure of well-conducted medical treatment and is intended for patients whose body mass index (BMI) is ≥ 40 kg/m2 or for those with BMI ≥ 35 kg/m2 who also have co-morbidities amenable to improvement, and in whom there are no contra-indications, particularly, those related to general anesthesia or psychological factors. The success and safety of surgical management requires preparation of the patient with regard to dietetic and nutritional counseling, and physical activity. The possibility of complications must be recognized and communicated, including, in view of the large variability of outcomes between individuals, the risk of failure and regain of weight. Prior to the operation, patients should be informed of and accept the program of postoperative clinical and laboratory follow-up, as well as the need for lifelong supplementation in micronutrients and the financial implications including what patients may have to pay out of their own pocket. Surgical management of obesity cannot replace the multidisciplinary medical management of severe obesity. The results obtained by BS are sustainable only if the patient adheres to the proposed modalities. New drugs such a GLP-1 analogues have opened encouraging perspectives as possible alternatives to BS in certain indications. [ABSTRACT FROM AUTHOR]

Background: Few studies have assessed changes in antihypertensive and lipid‐lowering therapy after bariatric surgery. The aim of this study was to assess the 6‐year rates of continuation, discontinuation or initiation of antihypertensive and lipid‐lowering therapy after bariatric surgery compared with those in a matched control group of obese patients. Methods: This nationwide observational population‐based cohort study used data extracted from the French national health insurance database. All patients undergoing gastric bypass or sleeve gastrectomy in France in 2009 were matched with control patients. Mixed‐effect logistic regression models were used to analyse factors that influenced discontinuation or initiation of treatment over a 6‐year interval. Results: In 2009, 8199 patients underwent primary gastric bypass (55·2 per cent) or sleeve gastrectomy (44·8 per cent). After 6 years, the proportion of patients receiving antihypertensive and lipid‐lowering therapy had decreased more in the bariatric group than in the control group (antihypertensives: –40·7 versus –11·7 per cent respectively; lipid‐lowering therapy: –53·6 versus –20·2 per cent; both P < 0·001). Gastric bypass was the main predictive factor for discontinuation of therapy for hypertension (odds ratio (OR) 9·07, 95 per cent c.i. 7·72 to 10·65) and hyperlipidaemia (OR 11·91, 9·65 to 14·71). The proportion of patients not receiving treatment at baseline who were subsequently started on medication was lower after bariatric surgery than in controls for hypertension (5·6 versus 15·8 per cent respectively; P < 0·001) and hyperlipidaemia (2·2 versus 9·1 per cent; P < 0·001). Gastric bypass was the main protective factor for antihypertensives (OR 0·22, 0·18 to 0·26) and lipid‐lowering medication (OR 0·12, 0·09 to 0·15). Conclusion: Bariatric surgery is associated with a good discontinuation of antihypertensive and lipid‐lowering therapy, with gastric bypass being more effective than sleeve gastrectomy. Drugs often stopped [ABSTRACT FROM AUTHOR]

Objectives: To identify risk factors for conversion, develop a predictive Conversion Risk Score (CRS), and assess the association between conversion and severe postoperative complications., Background: Conversion occurs in 15-30% of minimally invasive left pancreatectomies (MILP). Risk factors and potential negative impacts on postoperative outcomes are poorly described., Methods: Retrospective, nationwide, multicenter study including all MILP (laparoscopy and robot) performed between 2010 and 2021. Risk factors for conversion were identified by multivariate mixed model, and a CRS was developed on a "training-set" and validated (calibration diagrams and ROC curves) on a "validation-set." The association between severe complications and conversion was assessed using a propensity score based on the main risk factors for severe complications: age, sex, BMI, ASA score, tumor malignancy, multi-organ resection, operative duration, blood loss, splenectomy., Results: 2104 patients included from 55 centers. Conversion occurred in 15.6% of MILP. Its risk factors were male sex (OR=1.67;P=0.048), BMI≥25 kg/m2 (OR=2.15;P=0.004), history of laparotomy (OR=2.9;P<0.001), initial pancreatitis (OR=3.58;P=0.007), tumor size≥40 mm (OR=2.12;P=0.003), planned splenectomy (OR=2.63;P<0.001), unplanned splenectomy (OR=4.05;P=0.028), portal vein resection (OR=36.3;P=0.002), multi-organ resection (OR=12.97;P<0.001). A predictive CRS was created based only on preoperatively available variables (the first six), with scores ranging from 0 to 7, corresponding to a conversion risk of 2% to 100%. No association was observed with tumor malignancy, robotic approach, or pancreatectomy volume. Conversion was significantly associated with severe complications [OR=1.80(1.16-2.54)], independent of other risk factors for complications., Conclusions: Conversion during MILP can be predicted by CRS, aiding surgeons in decision-making, given its significant association with severe complications., Competing Interests: CONFLICT OF INTEREST DISCLOSURES: No disclosures reported., (Copyright © 2025 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Venous thromboembolism is a well-recognized complication after hepatopancreatobiliary surgery. However, there is a paucity of nationwide data on risk factors and incidence within 1 year of surgery in patients undergoing hepatopancreatobiliary surgery., Methods: This nationwide observational population-based cohort study used data extracted from all patients undergoing surgery for cancer surgery of the liver and the pancreas in France between 1 January 2015 and 31 December 2017. Estimation of 1 postoperative year cumulative incidence of venous thromboembolism and Cox proportional hazards model on 1-year global mortality were performed., Results: During the study period, 16,960 patients underwent cancer surgery of the liver (n = 9,381) or pancreas (n = 7,579). The 90-day postoperative rate of venous thromboembolism was 6.1% (cancer surgery of the liver) and 6.7% (cancer surgery of the pancreas). Main risk factors of 90-day postoperative rate of venous thromboembolism were major hepatectomy (1.85; 1.55-2.21), left pancreatectomy (1.45; 1.18-1.79), presence of obesity (1.41; 1.16-1.71), history of venous thromboembolism (4.58; 3.41-6.14), open approach (1.31; 1.06-1.62), and the occurrence of serious surgical complication (1.55; 1.35-1.79). At 1 year, patients undergoing cancer surgery of the liver were at a lower risk of cumulative incidence (%) of venous thromboembolism compared with the cancer surgery of the pancreas group (P < .001) (7.0; 6.5-7.6 vs 9.8; 9.1-10.4). Patients with venous thromboembolism within 1 year had greater risks of 1-year global mortality for each hepatopancreatobiliary surgery group: 3.58 (95% confidence interval, 3.02-4.23) and 3.97 (95% confidence interval, 3.40-4.63), respectively., Conclusion: Postoperative venous thromboembolism is a significant issue after hepatopancreatobiliary surgery, within 90 days postoperatively and up to 1 year, with the cancer surgery of the pancreas group being particularly at risk. A greater risk of global mortality within 1 year for patients experiencing early or late venous thromboembolism was found., Competing Interests: Conflict of Interest/Disclosure J.T. reports personal fees from Sanofi and Viatris outside the submitted work. F.C. reports having received research grant support from Bristol-Myers Squibb/Pfizer and Bayer and fees for board memberships or symposia from Bayer, Bristol-Myers Squibb/Pfizer, Merck Sharp and Dohme, Sanofi, Leo Pharma, Janssen, and Astra Zeneca and having received travel support from Bayer, Bristol-Myers Squibb/Pfizer, Merck Sharp and Dohme, Leo Pharma, and Astra Zeneca., (Copyright © 2025 Elsevier Inc. All rights reserved.)

Background: The resolution of obstructive sleep apneas syndrome (OSAS) following bariatric surgery appears to be promising for the majority of patients although this resolution does not necessarily exhibit a linear correlation with weight loss. Previous small-scale studies have pinpointed a younger age and preoperative weight under 100kg as predictive factors of OSAS improvement OBJECTIVES: The primary objective was to evaluate the evolution of OSAS in patients treated with continuous positive airway pressure (CPAP). Additionally, we tried to identify potential predictive factors for OSAS improvement postsurgery., Setting: Brest Hospital, France, University Hospital., Methods: In this retrospective, observational study we analyzed a cohort of 44 patients who underwent bariatric surgery, between January 2015 and December 2021. Each patient underwent respiratory polygraphy (RP) or polysomnography (PSG) before and after the surgical procedure. We collected CPAP data (including effective pressure and adherence) before and during the 6 months following the intervention., Results: Within the study population, 68.18% of patients exhibited improved OSAS, as defined as an apnea-hypopnea index of less than 15 per hour. A higher mean oxygen saturation prior to surgery emerged as the sole predictive factor for OSAS improvement. CPAP adherence and therapeutic pressure value, 2 rarely studied parameters, did not show significant difference between improved and nonimproved patients., Conclusions: The rate of OSAS resolution after surgery is 68.18%, with only a higher mean oxygen saturation before surgery identified as a predictive factor for OSAS resolution., (Copyright © 2025 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The need for conversional metabolic and bariatric surgery (CMBS) is still growing. No large-scale prospective cohort studies have assessed changes in lipid-lowering treatment (LLT) after CMBS., Objectives: This study assesses and compares the effectiveness of the 4 main CMBS sequences after sleeve gastrectomy (SG) and adjustable gastric banding (AGB) on reimbursement and cost of LLT., Setting: France., Methods: This nationwide observational population-based cohort study analyzed data from the French National Health Insurance database. It included all patients who had undergone primary SG and AGB in France between January 1, 2012, and December 31, 2014, and followed until December 31, 2020. The study assessed LLT reimbursement evolution and costs across 4 different CMBS sequences., Results: During follow-up, 6396 patients underwent the 4 CMBS sequences: SG-RYGB (Roux-en-Y gastric bypass) (n = 2400), AGB-SG (n = 2277), AGB-RYGB (n = 1173), and SG-SG (n = 546), with a rate of LLT reimbursement of 9.8%, 3.6%, 6.6%, and 7.9%, respectively, in the year before CMBS. The rates of discontinuation of treatment at 2 and 4 years were 41.9%, 35.4%, 45.6%, 20.5% and 45.6%, 31.3%, 64.3%, 31.6%, respectively. At 4 years, the median [interquartile range] annual costs (euros) per patient were significantly lower (P < .01) than the costs in the year before CMBS for each sequence: 86.8 [57.3; 136.1] versus 38.0 [.0; 64.6], 79.1 [50.5; 120.1] versus 50.4 [15.6; 64.1], 89.0 [66.5; 139.6] versus .0 [.0; 58.8], and 89.8 [66.1; 121.4] versus 63.1 [.0; 93.4]., Conclusions: Our study underlines the effectiveness of CMBS in significantly reducing the need and associated costs of LLT for patients with dyslipidemia over a 4-year period., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: This study assesses the effectiveness of 5 main conversional or revisional metabolic bariatric surgery sequences after sleeve gastrectomy, adjustable gastric banding and gastric bypass on reimbursement and cost of continuous positive airway pressure therapy, the first line treatment for obstructive sleep apnea, in France., Methods: This nationwide observational population-based cohort study analyzed data from the French National Health Insurance database. It included all patients who had undergone primary metabolic bariatric surgery in France between January 1, 2012, and December 31, 2014, and followed until December 31, 2020. The study assessed continuous positive airway pressure therapy reimbursement discontinuation and costs of reimbursed continuous positive airway pressure therapy across 5 different conversional or revisional metabolic bariatric surgery sequences., Results: During follow-up, 6,396 patients underwent the following sequences: sleeve gastrectomy-gastric bypass (n = 2,400), adjustable gastric banding-sleeve gastrectomy (n = 2,277), adjustable gastric banding-gastric bypass (n = 1,173), sleeve gastrectomy-sleeve gastrectomy (n = 546), and gastric bypass-others (n =332), with a rate of obstructive sleep apnea of 15.2%, 12.4%, 15.5% 12.8%, and 9.9% in the year before conversional or revisional metabolic bariatric surgery. The rates of patients who had a discontinuation of continuous positive airway pressure were at 2 and 4 years: 41.1%, 41.9%, 46.4%, 29.3%, and 33.3%; 62.3%, 57.0%, 78.2%; 57.5%, and 44.4%, respectively. At 4 years, the mean annual costs (euros) of obstructive sleep apnea treatment per patient were significantly lower (P < .01) than the costs in the year before conversional or revisional metabolic bariatric surgery for each sequence: 526.9 ± 414.4 vs 257.4 ± 349.7; 368.0 ± 247.5 vs 230.9 ± 288.4; 433.7 ± 326.0 vs 116.8 ± 238.3; 540.7 ± 275.3 vs 248.0 ± 308.4 and 501.2 ± 254.0 vs 281.1 ± 287.0, respectively., Conclusions: Our study underscore the effectiveness of conversional or revisional metabolic bariatric surgery in significantly reducing the need and associated costs of continuous positive airway pressure therapy for patients with obstructive sleep apnea postprimary metabolic bariatric surgery over a 4-year period., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Bariatric surgery (BS) induces significant changes in gastrointestinal anatomy, potentially influencing the pharmacokinetics of orally administered drugs such as rivaroxaban., Objectives: This phase 1 study aimed to assess the pharmacokinetics and safety of full-dose rivaroxaban in post-BS patients., Methods: The ABSORB (Rivaroxaban Pharmacokinetics and Pharmacodynamics After Bariatric Surgery and in Morbid Obesity) study was a single-center, nonrandomized, multiple-dose, parallel-design bioequivalence trial. Adult patients with stable weight after Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) were compared with subjects with class III obesity and healthy controls. Participants received 20 mg of rivaroxaban daily for 8 days., Results: Post-BS patients exhibited altered rivaroxaban pharmacokinetics, suggesting reduced absorption. Mean area under the concentration-time curve from time 0 to 24 hours after the first dose (RYGB, 1806.8 ng.h/mL; SG, 1648.9 ng.h/mL) was lower compared with that in controls (1893.5 ng.h/mL). At steady state, the area under the concentration-time curve values remained lower in BS groups (RYGB, 2129.9 ng.h/mL; SG, 1946.4 ng.h/mL) than in controls (2224.8 ng.h/mL). The maximum concentration after the first dose was lower in post-RYGB subjects (214.9 ng/mL) than in controls (264.1 ng/mL). This difference was less pronounced at steady state (RYGB, 256.9 ng/mL vs controls, 288.8 ng/mL). Neither BS group met bioequivalence criteria compared with controls, whereas the group with class III obesity met bioequivalence criteria compared with controls at steady state., Conclusion: Rivaroxaban displayed minor pharmacokinetic variations in post-BS patients. Given reported interindividual variability in the general population, these variations are unlikely to be of clinical significance. Our findings support rivaroxaban use in BS patients, emphasizing the need for further research in this area., Competing Interests: Declaration of competing interests J.T. reports personal fees from Sanofi and Viatris outside the submitted work. F.C. reports having received research grant support from Bristol Myers Squibb/Pfizer and Bayer and fees for board memberships or symposia from Bayer, Bristol Myers Squibb/Pfizer, Merck Sharp and Dohme, Sanofi, Leo Pharma, Janssen, and Astra Zeneca and has received travel support from Bayer, Bristol Myers Squibb/Pfizer, Merck Sharp and Dohme, Leo Pharma, Astra Zeneca, Sanofi, and Chiesi. The remaining authors have no known competing interests related to this work., (Copyright © 2024 International Society on Thrombosis and Haemostasis. Published by Elsevier Inc. All rights reserved.)

Introduction: Duodenal neuroendocrine tumours (D-NETs) have a low incidence; however, their diagnosis has been increasing. Features such as tumour location, size, type, histological grade, and stage were used to adapt the treatment to either endoscopic (ER) or surgical (SR) resections. There is no consensus regarding the definitive treatment. The authors' study aimed to describe the management of non-metastatic, well-differentiated D-NETs in France and its impact on patient survival., Methods: A registry-based multicenter study using prospectively collected data between 2000 and 2019, including all patients managed for non-metastatic G1 and G2 D-NETs, was conducted in the GTE group., Results: A total of 153 patients were included. Fifty-eight benefited from an ER, and 95 had an SR. No difference in recurrence-free survival (RFS) was observed regardless of treatment type. There was no significant difference between the two groups (ER vs. SR) in terms of location, size, grade, or lymphadenopathy, regardless of the type of incomplete resection performed or regarding the pre-therapeutic assessment of lymph node invasion in imaging. The surgery allowed for significantly more complete resection (patients with R1 resection in the SR group: 9 vs. 14 in the ER group, P <0.001). Among the 51 patients with positive lymph node dissection after SR, tumour size was less than or equal to 1 cm in 25 cases. Surgical complications were more numerous ( P =0.001). In the sub-group analysis of G1-G2 D-NETs between 11 and 19 mm, there was no significant difference in grade ( P =0.977) and location ( P =0.617) between the two groups (ER vs. SR). No significant difference was found in both morphological and functional imaging, focusing on the pre-therapeutic assessment of lymph node invasion ( P =0.387)., Conclusion: Regardless of the resection type (ER or SR) of G1-G2 non-metastatic D-NETs, as well as the type of management of incomplete resection, which was greater in the ER group, long-term survival results were similar between ER and SR. Organ preservation seems to be the best choice owing to the slow evolution of these tumours., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: French policymakers recently chose to regulate high-risk digestive cancer surgery (DCS). A minimum of five cases per year should be performed for each of the following types of curative cancer surgery: esophagus/esogastric junction (ECS), stomach (GCS), liver (LCS, metastasis included), pancreas (PCS), and rectum (RCS). This study aimed to evaluate the hypothetical beneficial effects of the new legal minimal volume thresholds on the rates of 90-day postoperative mortality (90POM) for each high-risk DCS., Methods: This nationwide observational population-based cohort study used data extracted from the French National Health Insurance Database from 1 January 2015-31 December 2017. Mixed-effects logistic regression models were performed to estimate the independent effect of hospital volume., Results: During the study period, 61,169 patients (57.1 % male, age 69.7 ±12.2 years) underwent high-risk DCS including ECS (n = 4060), GCS (n = 5572), PCS (n = 8598), LCS (n = 10,988), and RCS (n = 31,951), with 90POM of 6.6 %, 6.9 %, 6.0 %, 5.2 %, and 2.9 %, respectively. For hospitals fulfilling the new criteria, 90POM was lower after adjustment only for LCS (odds ratio [OR],15.2; 95 % confidence interval [CI], 9.5-23.2) vs OR, 7.6; 95 % CI, 5.2-11.0; p < 0.0001) and PCS (OR, 3.6; 95 % CI, 1.7-7.6 vs OR, 2.1; 95 % CI, 1.0-4.4; p<0.0001). With higher thresholds, all DCSs showed a lower adjusted risk of 90POM (e.g., OR, 0.38; 95 % CI, 0.28-0.51) for PCS of 40 or higher., Conclusion: Based on retrospective data, thresholds higher than those promulgated would better improve the safety of high-risk DCS. New policies aiming to further centralize high-risk DCS should be considered, associated with a clear clinical pathway of care for patients to improve accessibility to complex health care in France., (© 2024. Society of Surgical Oncology.)

Objective: This study compared the effectiveness of 4 main revisional bariatric surgery (RBS) sequences after sleeve gastrectomy (SG) and adjustable gastric banding (AGB), on the reimbursement of antidiabetic treatments in France., Background: Few large-scale prospective cohort studies have assessed the changes in antidiabetic treatments after RBS., Method: This nationwide observational population-based cohort study analyzed data from the French National Health Insurance Database. All patients who underwent primary SG and AGB in France between January 2012 and December 2014 were included and followed up until December 31, 2020. The changes in categories and costs of reimbursed antidiabetic treatments across different RBS sequences were assessed (presented as follows: bariatric surgery (BS)-RBS)., Results: Among the 107,088 patients who underwent BS, 6396 underwent RBS, 2400 SG-GBP (SG converted to gastric bypass [GBP] during follow-up), 2277 AGB-SG, 1173 AGB-GBP, and 546 SG-SG. Pre-RBS insulin was used in 10 (2.9%), 4 (0.9%), 8 (2.4%), and 10 (2.6%) patients, respectively. Two years after RBS, the treatment discontinuation or decrease (the change of treatment to a lighter one category rates [eg, insulin to bi/tritherapy]) was 47%, 47%, 49%, and 34%, respectively. Four years after RBS, the median annual cost per patient compared with baseline was lower ( P < 0.01) for all sequences, except SG-SG ( P = 0.24). The most notable effect concerned AGB-GBP (median of more than 220 euros to 0)., Conclusions: This study demonstrated the positive impact of RBS over a 4-year follow-up period on antidiabetic treatments reimbursement, through the reduction or discontinuation of treatments and a significant decrease in costs per patient., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Venous thromboembolism (VTE) is a well-recognized complication following gastrointestinal cancer surgery, particularly early postoperatively. The incidence and risk factors of VTE within 1-year after esophageal (including esophago-gastric junction) (ECS) and gastric (GCS) cancer surgeries, and especially its impact on 1-year global mortality, are yet under-explored., Methods: This nationwide observational population-based cohort study used data extracted from all patients undergoing ECS and GCS in France between 1 January 2015 and 31 December 2017. Multivariate logistic regression was used to identify risk factors for 90 postoperative days (POD) VTE (OR 95% CI). Cox proportional hazards models investigated the impact of 1-year postoperative VTE on 1-year global mortality [HR (95% CI)]., Results: During the study period, 8005 patients underwent ECS ( N =3429) or GCS ( N =4576) (31.8% female; 66.7±12.1 years old). Majority ( N =4951) of patients had preoperative treatment (chemotherapy or radiochemotherapy). Ninety POD incidence of VTE were 4.7% (ECS=6.2%) (GCS=3.6%) (44.7% during first hospitalization, 19.0% needing readmission, and 36.3% ambulatory management). Main risk factors were three and two field esophagectomy [3.6 (2.20-5.83) and 2.2 (1.68-3.0)], obesity [1.9 (1.40-2.58)] and history of VTE [5.1 (2.72-9.45)]. Late-onset VTE rates (occurring between the 6th and 12th month) represented 1.80 and 1.46% of the overall ECS and GCS groups. Patients with VTE within 1-year had higher risks of 1-year global mortality: (2.04 1.52; 2.73) and 2.71 (2.09; 3.51), respectively., Conclusion: Our extensive analysis of a nationwide database highlights the significant risk of postoperative VTE after ECS and GCS, persisting within 90 POD and up to 1-year. Crucially, a higher risk of global mortality within 1-year for patients experiencing early or late VTE was found. These findings could advocate for further research into extended prophylactic regimens, particularly for those most at risk., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background:  Previous studies have reported inconsistent findings regarding the association between obstructive sleep apnea (OSA) and incident venous thromboembolism (VTE). More specifically, the association between OSA and unprovoked VTE was barely evaluated. We aimed to evaluate whether apnea hypopnea index (AHI) and nocturnal hypoxemia markers were associated with unprovoked VTE incidence in patients investigated for OSA., Material and Methods:  Data from the Pays de la Loire Sleep Cohort were linked to the French health administrative data to identify incident unprovoked VTE in patients suspected for OSA and no previous VTE disease. Cox proportional hazards models were used to evaluate the association of unprovoked VTE incidence with AHI and nocturnal hypoxemia markers including the time spent under 90% of saturation (T90), oxygen desaturation index, and hypoxic burden (HB), a more specific marker of respiratory events related to hypoxia. The impact of continuous positive airway pressure (CPAP) was evaluated in the subgroup of patients who were proposed the treatment., Results:  After a median [interquartile range] follow-up of 6.3 [4.3-9.0] years, 104 of 7,355 patients developed unprovoked VTE, for an incidence rate of 10.8 per 1,000 patient-years. In a univariate analysis, T90 and HB predicted incident VTE. In the fully adjusted model, T90 was the only independent predictor (hazard ratio: 1.06; 95% confidence interval: [1.01-1.02]; p  = 0.02). The CPAP treatment has no significant impact on VTE incidence., Conclusion:  Patients with more severe nocturnal hypoxia are more likely to have incident unprovoked VTE., Competing Interests: W.T. reports support for attending meetings by ASTEN SANTE. C.G.-P. has nothing to disclose. B.H. has nothing to disclose. M.B. has nothing to disclose. N.M. reports support for attending meetings by ASTEN SANTE. M.J. has nothing to disclose. S.K. has nothing to disclose. R.L.M. received support for attending meetings by Astra Zeneca, GSK and Orkyn, and consulting fees from Astra Zeneca and GSK, outside the submitted work. E.M. has nothing to disclose. J.-L.R. has nothing to disclose. A.S. has nothing to disclose. J.T. received fees from Laboratoire Pierre Fabres, outside the submitted work. F.C. received consulting fees from Bayer, Pfizer, Astra, MSD, GSK, Leopharma, outside the submitted work. F.G. received support for attending meetings by ASTEN SANTE and ACTELION and consulting fees from NYXOAH, SEFAM, RESMED, CIDELEC, ASTEN SANTE, and BOEHRINGER INGELHEIM, outside the submitted work., (Thieme. All rights reserved.)

Objective: To describe the management of pathogenic CDH1 variant carriers (pCDH1vc) within the FREGAT (FRench Eso-GAsTric tumor) network. Primary objective focused on clinical outcomes and pathological findings, Secondary objective was to identify risk factor predicting postoperative morbidity (POM)., Background: Prophylactic total gastrectomy (PTG) remains the recommended option for gastric cancer risk management in pCDH1vc with, however, endoscopic surveillance as an alternative., Methods: A retrospective observational multicenter study was carried out between 2003 and 2021. Data were reported as median (interquartile range) or as counts (proportion). Usual tests were used for univariate analysis. Risk factors of overall and severe POM (ie, Clavien-Dindo grade 3 or more) were identified with a binary logistic regression., Results: A total of 99 patients including 14 index cases were reported from 11 centers. Median survival among index cases was 12.0 (7.6-16.4) months with most of them having peritoneal carcinomatosis at diagnosis (71.4%). Among the remaining 85 patients, 77 underwent a PTG [median age=34.6 (23.7-46.2), American Society of Anesthesiologists score 1: 75%] mostly via a minimally invasive approach (51.9%). POM rate was 37.7% including 20.8% of severe POM, with age 40 years and above and low-volume centers as predictors ( P =0.030 and 0.038). After PTG, the cancer rate on specimen was 54.5% (n=42, all pT1a) of which 59.5% had no cancer detected on preoperative endoscopy (n=25)., Conclusions: Among pCDH1vc, index cases carry a dismal prognosis. The risk of cancer among patients undergoing PTG remained high and unpredictable and has to be balanced with the morbidity and functional consequence of PTG., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

While research publications on bariatric surgery (BS) have grown significantly over the past decade, there is no mapping of the existing body of evidence on this field of research. We performed a systematic review followed by a mapping of randomized controlled trials (RCTs) in BS for people with obesity. From January 2020 to December 2020, we performed a systematic review of RCTs evaluating BS, versus another surgical procedure, or versus a medical control group, through a search of Embase and PubMed. There was no restriction on outcomes for study selection. A total of 114 RCTs were included, most (73.7%) of which were based on a comparison with Roux-en-Y gastric bypass (RYGB) and conducted between 2010 and 2020. Only 15% of the trials were multicenter and few (3.5%) were international. The median number of patients enrolled was 61 (interquartile range [IQR]: 47.3-100). Follow-up time was 1 to 2 years in 36% and 22.8% of the trials, respectively. Weight loss was the most studied criterion (87% of RCTs), followed by obesity-related diseases, and medical and surgical complications (73%, 54%, and 47% of RCTs, respectively). Nutritional deficiency frequency, body composition, and mental health were little studied (20%, 18% and 5% of RCTs, respectively). Our literature review revealed that much research in BS is wasted because of replication of RCTs on subjects for which there is already body of evidence, with small populations and follow-up times mostly below 2 years. Yet several research questions remain unaddressed, and there are few long-term trials. Future studies should take into account the experience of the past 70 years of research in this field., (© 2022 World Obesity Federation.)

Objectives: To systematically identify the strategy and frequency of spin in reports of bariatric surgery randomized controlled trials (RCTs) with statistically nonsignificant primary endpoint., Study Design and Setting: The use of specific reporting strategies to highlight the beneficial effect of an experimental treatment can affect the reader interpretation of trial results, particularly when the primary endpoint is not statistically significant. A literature search was performed to identify RCTs publications assessing the impact of bariatric surgery on obesity-related comorbidities published over the past 10 years (from January 2020 till December 2020) in MEDLINE and EMBASE. RCTs publications with statistically non-significant primary outcomes were included., Results: Of 46 576 reports screened for title and abstract inclusion, 29 RCT reports met the inclusion criteria for spin analysis. In total, 16 abstracts (55%) and 18 main texts (62%) were classified as having a spin. In abstract results and conclusion sections, the spin was identified in 69% of reports. In main text results, discussion, and conclusion sections, the spin was recognized in 37%, 72%, and 76% of reports respectively. The spin consisted mainly of focusing on within-group improvements and the interpretation of statistically nonsignificant results as showing treatment equivalence., Conclusion: Spin occurred in a high proportion of bariatric surgery RCTs with a statistically nonsignificant primary endpoint., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

The prevalence of obesity has been steadily increasing in recent years worldwide. At the same time bariatric surgery, the best therapeutic strategy to date in terms of sustainable weight loss and improvement of associated comorbidities has been also increasing. However, these surgeries, whether primarily restrictive or malabsorptive, raise questions about the pharmacology of oral drugs. Among widely used drugs, anticoagulants are the referent therapy to treat some cardiovascular diseases such as atrial fibrillation and venous thromboembolism. How bariatric surgery may impact pharmacological properties of oral anticoagulants, and more specifically, direct oral anticoagulants (DOACs) are difficult to anticipate. In this review, we describe available data concerning the potential impact of bariatric surgery on the pharmacology of oral anticoagulants. The vitamin K antagonists (VKAs) requirements for the same international normalized ratio target are reduced after bariatric surgery. Limited data available for dabigatran 150 mg twice daily indicate a risk of insufficient efficacy in atrial fibrillation after gastric bypass due to probable impaired absorption. Data for rivaroxaban at the prophylactic dose of 10 mg per day suggest no impact of bariatric surgery from 3 days to 8 months post-surgery. However, no conclusive data are available for other anticoagulants or the use of DOACs at therapeutic doses. To date, DOACs are not recommended in patients who have undergone bariatric surgery, because of limited available data. Pending new studies to confirm the predictable pharmacokinetics and safety of DOACs in this population, especially at therapeutic doses, VKAs remain the first option for chronic anticoagulation., (© 2020 Société Française de Pharmacologie et de Thérapeutique.)

Background: While the benefits of bariatric surgery (BS) on pregnancy outcomes have been demonstrated for women compared with matched controls on presurgery body mass index (pB-BMI), data are lacking and those benefits are uncertain compared with matched controls on prepregnancy BMI (pP-BMI)., Objectives: Our study aimed to evaluate outcomes (obstetrical and neonatal) of single pregnancy in women previously exposed to BS compared with women unexposed to BS matched on pB-BMI and pP-BMI., Settings: Retrospective matched cohort study from 2 observational studies of pregnant women conducted in a French administrative county (Finistère)., Methods: From April 1, 2015 to January 31, 2019, pregnant women with previous BS (n = 52) were included and compared with 2 different control groups as follows: group A (n = 104), matched for pB-BMI, age, and parity; and group B (n = 104), matched for pP-BMI, age, and parity., Results: In women exposed to BS, mean age was 27.1 (±4.9) years and pB-BMI was 46.0 (±4.6) kg/m 2 . Operated women differed significantly from group A but not from group B for pP-BMI (29.4 ± 6.1 versus 45.3 ± 4.5 group A versus 28.6 ± 6.6 group B) and gestational diabetes (12.0% versus 44.0% group A versus 17.0% group B), respectively. In the group of women exposed to BS, birth weight (g) was significantly lower (2960 ± 545 versus 3381 ± 735 group A versus 3310 ± 645 group B) and large-for-gestational-age infants less frequent (0% versus 13% group A versus 8% group B)., Conclusion: Bariatric surgery reduced risks of excessive fetal growth and gestational diabetes with a trend for a higher risk of small-for-gestational-age, despite matching on pP-BMI suggesting a risk associated to BS and solely to previous surgery-induced weight loss., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Type II AEG is now considered as oesophageal cancer in the seventh and eighth edition of TNM classification but optimal surgical approach for these tumors remains debated. The objective of the study is to assess and compare surgical and oncological outcomes of two surgical approaches: superior polar oesogastrectomy (SPO) or total gastrectomy (TG) in patients with type II adenocarcinoma of the oesophagogastric junction (AEG)., Material and Methods: 183 patients with type II AEG treated from 1997 to 2010 in 21 French centers by SPO or TG were included in a multicenter retrospective study. The surgical and oncological outcomes were compared between these two surgical approaches., Results: A TG was performed in 64 (35%) patients whereas 119 (65%) patients were treated by SPO with transthoracic approach in 100 of them (83.2%) and transhiatal approach with cervicotomy in 19 (16.8%). Surgical outcomes were comparable between the two approaches with a postoperative mortality rate of 4.9% and a severe operative morbidity rate within 30 days of 15.3%. Median survival in patients operated on by TG was of 46 months compared to 27 months in patients treated by SPO (p = 0.118). At multivariate analysis, TG appears to be an independent good prognostic factor compared to SPO (HR = 1.847; p = 0.008). However, TG was also associated with a higher rate of incomplete resection, (12.5% vs 5.9%; p = 0.120)., Conclusion: When TG allows obtaining tumor-free resection margins, this approach should be preferred to SPO., (Copyright © 2019 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: Concerns are rising about the late adverse events following gastric bypass and sleeve gastrectomy. We aimed to assess, over a 7-year period, the late adverse events after gastric bypass and sleeve gastrectomy compared with matched control groups., Methods: In this nationwide, observational, population-based, cohort study, we used data extracted from the French National Health Insurance (Système National des Données de Santé) database. All patients undergoing gastric bypass or sleeve gastrectomy in France in 2009, except those who had undergone bariatric surgery in the previous 4 years before inclusion, were matched with control patients with obesity in terms of age, sex, BMI category, baseline antidiabetic therapy, and baseline insulin therapy. Exclusion criteria for the control group included cancer, pregnancy, chronic infectious disease, serious acute or chronic disease in 2008-09, or previous (2005-09) or forthcoming (2010-11) bariatric surgery. The incidence rate was calculated for each type of adverse event leading to inpatient hospital admission over a 7-year period; incidence rate ratios (with 95% CIs) were computed to compare the rate of complications among the bariatric surgery and control groups. Risks of complications during follow-up were compared using Cox proportional-hazards regression analyses. Data were analysed according to the intention-to-treat methodology., Findings: From Jan 1, 2009, to Dec 31, 2009, 8966 patients who underwent bariatric surgery (7359 [82%] women; mean age 40·4 years [SD 11·3]) and 8966 matched controls (7359 [82%] women; mean age 40·9 years [11·4]) were included in analyses 4955 (55%) off 8966 patients in the bariatric surgery group had a primary gastric bypass and 4011 (45%) patients had sleeve gastrectomy. With a mean follow-up of 6·8 years (SD 0·2), mortality was lower in the gastric bypass group than in its control group (hazard ratio 0·64 [95% CI 0·52-0·78]; p<0·0001) and in the sleeve gastrectomy group than in its control group (0·38 [0·29-0·50]; p<0·0001). The gastric bypass and sleeve gastrectomy groups had higher risk than did their control groups for invasive gastrointestinal surgery or endoscopy (incidence rate ratio 2·4 [95% CI 2·1-2·7], p<0·0001, for gastric bypass vs control and 1·5 [1·3-1·7], p<0·0001, for sleeve gastrectomy vs control); for gastrointestinal disorders not leading to invasive procedures (1·9 [1·7-2·1]), p<0·0001, for gastric bypass vs control and 1·2 [1·1-1·4], p<0·0001, for sleeve gastrectomy vs control); and for nutritional disorders (4·9 [3·8-6·4], p<0·0001, for gastric bypass vs control and 1·8 [1·3-2·5], p<0·0001, for sleeve gastrectomy vs control). For psychiatric disorders, there was no significant association (1·1 [0·9-1·4], p=0·190, for gastric bypass vs control and 1·1 [0·8-1·3], p=0·645, for sleeve gastrectomy vs control), except for gastric bypass and alcohol dependence (1·8 [1·1-2·8], p=0·0124)., Interpretation: Despite lower 7-year mortality, patients undergoing gastric bypass or sleeve gastrectomy had higher risk of hospital admission at least once for late adverse events, except for psychiatric disorders, than did control patients, with a higher risk observed after gastric bypass than with sleeve gastrectomy., Funding: None., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Importance: Few large-scale long-term prospective cohort studies have assessed changes in antidiabetes treatment after bariatric surgery., Objective: To describe the association between bariatric surgery and rates of continuation, discontinuation, or initiation of antidiabetes treatment 6 years after bariatric surgery compared with a matched control obese group., Design, Setting, and Participants: This nationwide observational population-based cohort study extracted health care reimbursement data from the French national health insurance database from January 1, 2008, to December 31, 2015. All patients undergoing primary bariatric surgery in France between January 1 and December 31, 2009, were matched on age, sex, body mass index category, and antidiabetes treatment with control patients hospitalized for obesity in 2009 with no bariatric surgery between 2005 and 2015., Exposures: Bariatric surgery, including adjustable gastric banding (AGB), gastric bypass (GBP), and sleeve gastrectomy (SG)., Main Outcome and Measure: Reimbursement for antidiabetes drugs. Mixed-effects logistic regression models estimated factors of discontinuation or initiation of antidiabetes treatment over a period of 6 years., Results: In 2009, a total of 15 650 patients (mean [SD] age, 38.9 [11.2] years; 84.6% female; 1633 receiving antidiabetes treatment) underwent primary bariatric surgery, with 48.5% undergoing AGB, 27.7% undergoing GBP, and 22.0% undergoing SG. Among patients receiving antidiabetes treatment at baseline, the antidiabetes treatment discontinuation rate was higher 6 years after bariatric surgery than in controls (-49.9% vs -9.0%, P < .001). In multivariable analysis, the main predictive factors for discontinuation were the following: GBP (odds ratio [OR], 16.7; 95% CI, 13.0-21.4), SG (OR, 7.30; 95% CI, 5.50-9.50), and AGB (OR, 4.30; 95% CI, 3.30-5.60) compared with no bariatric surgery, as well as insulin use (OR, 0.17; 95% CI, 0.13-0.22), dual therapy without insulin (OR, 0.38; 95% CI, 0.32-0.45) vs monotherapy, lipid-lowering treatment (OR, 0.76; 95% CI, 0.63-0.91), antidepressant treatment (OR, 0.67; 95% CI, 0.55-0.81), and age (OR, 0.96; 95% CI, 0.95-0.97) per year. For patients without antidiabetes treatment at baseline, the 6-year antidiabetes treatment initiation rate was much lower after bariatric surgery than in controls (1.4% vs 12.0%, P < .001). In multivariable analysis, protective factors were GBP (OR, 0.06; 95% CI, 0.04-0.09), SG (OR, 0.08; 95% CI, 0.06-0.11), and AGB (OR, 0.16; 95% CI, 0.14-0.20) vs controls, and risk factors were as follows: body mass index category (OR, 2.04; 95% CI, 1.68-2.47 for ≥50.0 vs 30.0-39.9 and OR, 1.68; 95% CI, 1.49-1.90 for 40.0-49.9 vs 30.0-39.9), antihypertensive treatment (OR, 1.49; 95% CI, 1.33-1.67), low income (OR, 1.43; 95 % CI, 1.26-1.62), and age (OR, 1.04; 95 % CI, 1.03-1.05) per year., Conclusions and Relevance: Bariatric surgery was associated with a significantly higher 6-year postoperative antidiabetes treatment discontinuation rate compared with baseline and with an obese control group without bariatric surgery.

Purpose: Surgery remains the mainstay of gastrointestinal stromal tumors (GISTs) treatment. The aim of our study was to compare postoperative outcomes and long term oncologic results of GISTs resection. An analysis of laparoscopic versus open surgery for GISTs and a subgroup analysis of lesions larger than 5 cm were realized., Materials and Methods: Between January 2005 and December 2014, 143 patients with primary GISTs were treated with radical resection in two tertiary centers. Eight patients with metastatic disease were excluded. The remaining patients were assigned to 2 groups: laparoscopy and open surgery. A separate analysis of tumors larger than 5 cm was realized for the laparoscopy group. Long-term follow-up was used to analyze the oncologic and surgical results. Relevant clinical variables were evaluated using univariate and multivariate analyses., Results: With similar oncological outcomes(p = 0.09) and morbidity(p = 0.56), laparoscopy compared to open surgery significantly reduced length of hospitalization (p = 0.01). For lesions >5 cm laparoscopic resection is associated with similar short-term outcomes with resection for small tumors without compromising oncological outcomes (p = 0.89). For all patients, the probability of remaining disease free at 3 years, and 5 years was 97, 6% and 95%, respectively., Conclusion: Laparoscopic resection is a technically and oncologically safe and feasible approach for GISTs compared with open resection. Resection of lesions superior of 5 cm by laparoscopy has efficacy and recurrence rates similar to open surgical controls. Large tumor resection should only be attempted by surgeons with a large experience with minimally invasive surgery in order to avoid operative complications and unfavorable long term outcome., (Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: The aim of the present study was to assess the incidence, risk factors, and the impact of posthospital discharge (PHD) chemoprophylaxis on venous thromboembolism (VTE) in patients undergoing bariatric surgery (BS)., Background: VTE is a major concern after BS, especially during the PHD period. No large-scale study has previously focused on the clinical value of PHD chemoprophylaxis., Methods: In this nationwide observational population-based cohort study, all data from patients undergoing BS were extracted from the French National Health Insurance database (SNIIRAM) from 1st January 2012 to 31st September 2014. Logistic regression models were used to compute odds ratios for potential risk factors for VTE occurring within 90 postoperative days (PODs). The association between use of PHD chemoprophylaxis (heparin) and VTE was also assessed., Results: The majority (56%) of the 110,824 patients had sleeve gastrectomy. VTE rates during the first 30 and 90 PODs were 0.34% and 0.51%, respectively. On multivariate analyses, the major risk factors for VTE during the first 90 PODs were history of VTE [odds ratio = 6.33 95% confidence interval (4.44-9.00)], postoperative complications [9.23 (7.30-11.70)], heart failure [2.45 (1.48-4.06)], and open surgery [2.38 (1.59-3.45)]. PHD chemoprophylaxis was delivered to 75% of patients. No use of PHD chemoprophylaxis [1.27 (1.01-1.61)] was an independent predictive factor of VTE during the first 90 PODs [in the gastric bypass group: 1.51 (1.01-2.29))., Conclusions: In the modern era of BS, this nationwide study shows a non-negligible rate of VTE especially after sleeve gastrectomy, depending on the individual risk level. Use of PHD chemoprophylaxis may decrease the risk of PHD VTE.

Purpose: The treatment of rectal cancer could be complex and the long term complications have the potential to greatly impact the quality of life. The aim of this study was to evaluate the long term functional and oncological results after sphincter-saving resection for rectal cancer., Methods: Between January 2005 and December 2013, a total of 187 rectal resections with total mesorectal excision (TME) for cancer were performed. The data of 72 (38.5%) patients were available for analysis. Long-term follow-up was used to analyze the oncologic and functional results. Standardized questionnaires were used to determine fecal incontinence and urinary function. Relevant clinical variables were evaluated using univariate and multivariate analyses., Results: The overall survival rate was 71% and the distribution of the International Union against Cancer (UICC) stages was 48.6% stage 1, 18% stage 2, and 33.3% stage 3. In univariate analysis, neoadjuvant radiotherapy (P < 0.01), rectal pouch (P < 0.01) and hand-sewn anastomosis (P = 0.02) was found to adversely affect fecal continence. On multivariate analysis fecal incontinence was significantly correlated with neoadjuvant radiochemotherapy (P < 0.05) and low rectal resection (P < 0.01). Urinary function was not statistically significant affected by preoperative treatment (P = 0.48) or surgical procedure (P = 0.45)., Conclusion: Tumor location, surgical technique and neoadjuvant treatment had an impact on long term oncologic and functional results after sphincter-saving resection for rectal cancer. Urinary dysfunction occurs less frequently than anal disorders. These results highlight the importance of functional evaluation before and after rectal cancer resection in daily clinical practice and the necessity to tailor treatment to each patient., (Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Venous thromboembolism (VTE) can be the first manifestation of cancer; however, the current incidence of malignancy in unselected patients with first unprovoked VTE needs to be confirmed., Material and Methods: Between March 1st, 2013 and February 28th, 2015 we included and followed-up all patients living in the Brest district, France, who were seen in hospitals or the community for a first symptomatic unprovoked VTE event. The primary study outcome was the one-year incidence of cancer., Results: 526 patients, mean age 66.6 ± 18.1 years, 246 (46.8%) men, were included in the study. In the year following VTE, 26 patients were diagnosed with cancer, corresponding to a one-year cumulative incidence of cancer of 5.06% (95% CI 3.47-7.35). Age ≥60, smoking and pulmonary embolism were significantly associated with cancer diagnosis in multivariate analysis. Fifty percent of cancers were patent at the time of VTE diagnosis, mostly detected on CTPA (Computed Tomographic Pulmonary Angiography) performed for pulmonary embolism assessment. After excluding patients with patent cancer at VTE diagnosis, the one-year incidence of cancer was 2.65% (95% CI: 1.55-4.52); in multivariate analysis, only current smoking was independently associated with a significant 5.4-fold increased risk for cancer diagnosis (HR 5.40; 95% CI 1.31-22.27). No cancer was diagnosed in patients aged 50 years or younger., Conclusion: The one-year incidence of cancer after a first unprovoked VTE was 5.06%. Half of the cancers were diagnosed during the diagnosis procedure for pulmonary embolism using CTPA., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Purpose: Obese patients are known to be in an in vitro hypercoagulable state relative to normal-weight patients. Our study aimed to identify markers of enhanced coagulability (endogenous thrombin potential (ETP)) in morbidly obese patients using the thrombin generation (TG) test., Materials and Methods: All patients scheduled for laparoscopic bariatric surgery (LBS) between September 1, 2014 and January 31, 2016 were eligible for our prospective study. We used logistic regression to compute the odds ratio (OR) across ETP quartile distributions to evaluate the risk of enhanced TG., Results: We studied 102 patients, 77.5% were female, mean age was 41.2 ± 12.1 years, and mean BMI was 45.5 ± 7.0 k/m 2 . Total cholesterol and fibrinogen levels were found to be independent risk factors for patients in the 4th quartile distribution of the ETP distribution (OR (95% CI)) 2.6 (1.2 to 5.4) (P = 0.01) and 2.2 (1.1 to 4.5 (P = 0.03). Patients in the 4th quartile of the ETP distribution had a lower ETP 1 month after surgery (157 (144-196) vs. 120 (98-140); P < 0.001) in parallel with a trend toward lower total cholesterol levels (5.0 ± 0.9 vs. 4.4 ± 1.0; P = 0.06). Fibrinogen levels were stable (4.5 ± 1.0 vs. 4.4 ± 0.9); P = 0.7)., Conclusions: Our study highlights the role of total cholesterol and blood inflammatory marker levels in enhancing ETP in morbidly obese patients. Further studies are necessary to confirm the decreased ETP following LBS with the expected reduced inflammatory marker and total cholesterol levels.

Background: Gastroesophageal reflux disease (GERD) is a common obesity-related co-morbidity that routinely is treated by continuous proton pump inhibitor (PPI) therapy. A number of concerns have been raised regarding the risk of de novo GERD or exacerbation of preexisting GERD after sleeve gastrectomy (SG)., Objective: To assess PPI use at 4 years after bariatric surgery., Setting: French National Health Insurance., Methods: Data were extracted from the French National Health Insurance database. All adult obese patients who had undergone gastric bypass (GBP) (n = 8250) or SG (n = 11,923) in 2011 in France were included. Patients were considered to be on continuous PPI therapy when PPIs were dispensed≥6 times per year. Logistic regression models were used to compute odds ratios for potential risk factors for PPI reimbursement 4 years after surgery., Results: Overall, continuous use of PPIs increased from baseline to 4 years after SG and GBP, from 10.9% to 26.5% (P<.001) and from 11.4% to 21.9% (P<.001), respectively. Among patients who underwent PPI therapy before surgery, those who had undergone SG were more likely to continue PPI therapy 4 years after surgery compared with those who underwent GBP (72.7% versus 59.2%; P<.001). In multivariate analyses, the major risk factors for persistent continuous PPI treatment 4 years after surgery were the following: SG (odds ratio [OR] = 1.87; 95% confidence interval [CI] 1.55-2.25), higher body mass index (OR 1.85; 95% CI 1.35-2.5), and preoperative antidepressant treatment (OR 1.89; 95% CI 1.56-2.29)., Conclusion: At a nationwide scale, continuous PPI treatment is used by 1 of 10 obese patients before bariatric surgery, but by 1 of 4 patients 4 years after surgery. SG compared with GBP, higher body mass index, and other coexisting conditions are the 3 major risk factors for medium-term continuous PPI therapy., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Colovesical fistulas (CVF) constitute the most common type of spontaneously occurring fistulas associated with diverticular disease. One-stage laparoscopic resection has been shown to be feasible, but studies comparing this approach to open surgery are scarce. The aim of this study was to compare the clinical outcomes of open and laparoscopic surgery for CVF of diverticular origin., Materials and Methods: From January 2000 to July 2014, 37 colectomies were performed for diverticular disease-related CVF. Twenty-eight patients who underwent resection and primary anastomosis were divided in 2 groups: the laparoscopic surgery group (group A) and the open surgery group (group B). We have analyzed the following parameters: operative time, complication rate, hospital stay, recurrence, and early mortality rate., Results: Groups A and B were comparable in terms of age, sex, diverticulitis episodes, previous abdominal surgery, and body mass index.The mean duration of surgery was significantly shorter in group B: 175 versus 237 minutes (P=0.011). There was a faster recovery of gastrointestinal transit in group A (2 vs. 13; P=0, 0002). However, there were no significant differences between the groups with respect to serious postoperative morbidity [(Clavien-Dindo scores of 3, 4, and 5) 4 vs. 0; P=0.098)] and with respect to hospital stay (10.5 vs. 9.5 d; P=0.537). There was no recurrence during a median follow-up of 12 months., Conclusions: Laparoscopic resection and primary anastomosis should be considered a safe and feasible option for the management of diverticular CVF. Despite progresses in minimally invasive colorectal surgery, the conversion rate and morbidity are still high.

Background: Obese patients are in a hypercoagulable state relative to normal-weight patients. Low-grade inflammation may be a key factor for this condition., Objectives: Our study aimed to compare the coagulability state of morbidly obese patients before and 1 year after bariatric surgery (BS) using the Thrombin Generation (TG) test, a validated method to assess coagulation in vitro., Setting: University hospital., Methods: All patients undergoing BS between September 1, 2014 and April 30, 2015 were eligible for this prospective study (n = 42). Two distinct reagents were used for TG initiation based on the tissue factor concentration (Reagents LOW and HIGH). The main outcomes were endogenous thrombin potential (ETP) and peak height of TG. The rate of follow-up after one year was 97%., Results: One year after surgery, %weight loss was 32.5±8.4%; CRP decreased from 9.0 (3.7-12.9) to 1.1 (0.3-2.8) mg/mL (P<.001) and fibrinogen from 4.2±.8 to 3.5±.8 g/L (P<.001). The ETP (%) decreased from (108.0 (95.0-117.0) to 78.0 (71.0-98.0) (P<.001) (LOW reagent) and from 113.0 (103.0-134.0) to 96.0 (86.0-107.0) (P<.001) (HIGH reagent). Peak height (%) decreased from (117.0 (92.0-139.0) to 82.0 (70.0-111.0) (P = .003) (LOW reagent) and from 106.0 (96.0-118.0) to 97.0 (87.8-105.2) (P = .003) (HIGH reagent)., Conclusion: Our study shows a significant reduction in TG potential one year after BS in morbidly obese patients. Reduction of low grade inflammation may be one of the underlying mechanisms., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Sleeve gastrectomy (LSG) and mini gastric bypass (LMGB) was considered as emerging procedures but are now considered for many authors as an alternative of the Roux-Y gastric bypass because of similar percentages of weight loss and better postoperative morbidity profiles. However, studies comparing LSG and LMGB are scarce., Materials and Methods: From January 2010 to July 2014, 262 and 161 patients underwent LSG or LMGB in two centre of bariatric surgery, respectively. At one year, rate of follow-up was 88.4%. Main outcome was % of Total Weight Loss (%TWL) at one year. Propensity score matching and multivariable analyses were used to compensate for differences in some baseline characteristics., Results: After matching LSG (N = 136) and LMGB (N = 136) groups did not differ for initial BMI (kg/m(2)) (43.4 ± 6.5 vs. 42.8 ± 5.0; P = 0.34), % of female patients (91.9% vs. 93.4%; P = 0.64), age (years) (41.2 ± 12.3 vs. 41.2 ± 11.3; P = 0.99) and diabetes (15.4% vs. 19.9%; P = 0.34). At one year, %TWL, change in BMI and rate of stenosis were higher for LMGB group, respectively: 38.2 ± 8.4 vs. 34.3 ± 8.4 (P < 0.0001); -16.5 ± 4.6 vs. -14.9 ± 4.4 (P = 0.005) and 16.9% vs. 0% (P < 0.0001). In multivariate analyses (β coefficient), LMGB was a positive independent factor of %TWL (2.8; P = 0.008)., Conclusion: LMGB seems to have better weight loss at one year compared to LSG with higher gastric complications. Further long term studies are needed., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

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.

Introduction: To evaluate the feasibility, safety, and short-term outcomes of primary closure (PC) and biliary drainage (BD), after the laparoscopic treatment of common bile duct (CBD) stones by choledocotomy., Patients and Methods: Between January 2009 and December 2014, 102 patients underwent laparoscopy for lithiasis of the CBD. Intraoperative cholangiography was systematically performed, followed by choledocoscopy, depending on the size of the CBD., Results: Eighty (78.4%) of the 102 patients underwent laparoscopic stone extraction by choledocotomy, and were assigned to 2 groups: PC (group A, n=25), and BD (group B, n=55). Groups A and B were comparable in terms of age (62.3±26.1 vs. 66.0±19.3 y; P=0.53), the percentage of women (72.0% vs. 76.4%; P=0.68), body mass index (25.9±6.1 vs. 26.9±4.4 kg/m; P=0.52), and CBD diameter (11.6±3.1 vs. 12.1±3.8 mm; P=0.59). The mean durations of surgery and of hospital stay were significantly shorter in group A: 179±38 versus 211±57 minutes (P=0.02) and 5.4±2.0 versus 8.4±3.2 days (P<0.001). Groups A and B were comparable in terms of serious postoperative morbidity (Clavien-Dindo scores of 3, 4, and 5): 2 versus 4 (P=1). In group B, bile drain removal was complicated by choleperitoneum in 3 cases., Conclusions: With shorter durations of surgery and hospital stay, equivalent postoperative morbi-mortality, and an absence of the specific morbidity due to bile drainage, PC may be considered a safe and feasible option for the laparoscopic management of CBD stones by choledocotomy.

Background: Laparoscopic sleeve gastrectomy (LSG) is the most frequently performed procedure for morbid obesity in France. However, in case of de novo gastroesophageal reflux disease or of insufficient weight loss, LSG could be converted in rare cases to laparoscopic Roux-en-Y gastric bypass (LRYGB). In case of voluminous incisional hernia (IH) associated, this procedure could be technically challenging, especially in cases of super-obesity (body mass index (BMI) ≥50 kg/m2). Furthermore, IH should be repaired in order to avoid life-threatening post-operative small bowel obstruction., Methods: We present the case of a 30-year-old woman (125 kg, 1.55 m) with a BMI of 52.1 kg/m2. She was referred to our tertiary care center for weight regain (Nadir 100 kg), 4 years after a LSG was performed for super-super obesity (BMI = 68.7 kg/m2). She also had a history of epigastric IH (single-incision LSG; diameter = 10 cm). The strategy adopted was to repair hernia with raphy. In case of hernia recurrence and of sustainable weight loss, use of prothetic mesh would be mandatory in the future., Results: In this multimedia video, we present a step-by-step laparoscopic conversion of sleeve gastrectomy to LRYGB for super-obesity (BMI ≥50 kg/m2) and incisional hernia. Laparoscopic procedure included adhesiolysis, dissection, and resection of the low part of the remnant stomach, gastro-jejunal circular anastomosis, and closure of aponeurosis defect., Conclusions: Incisional hernia and morbid obesity are often entangled problems. Revisional procedure of bariatric surgery with incisional hernia associated should be performed laparoscopically.

Introduction: Post-pancreaticoduodenectomy hemorrhage is mostly due to the gastroduodenal artery stump erosion. The diagnosis of arterial bleeding is done by digestive endoscopy, selective angiography or video capsule endoscopy. On failure of etiological research, surgery is the last resort despite its technical difficulties., Case Presentation: A 63 years-old woman was admitted in surgery, nine months after cephalic pancreaticoduodenectomy for a pain of the right hypochondria combined with a pneumoperitoneum, after a 3rd episode of hemorrhage. Exploratory laparotomy is performed after a third hemorrhagic episode and failure of etiological research. Bleeding from the gastroduodenal artery stump was discovered and successfully treated., Discussion: Post-pancreaticoduodenectomy hemorrhage can occur very late. In these cases, a secondary arterial erosion obstructed by left hemi-liver should not be excluded. In these cases, despite the technical risks, surgery is required., Conclusion: The failure of the means used for diagnostic must lead to the surgery right away, despite operating risk., (Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: Vertical banded gastroplasty (VBG) has been demonstrated to be disappointing for long-term weight loss and quality of life (Br J Surg 100:222–230, 2013). Laparoscopic revisional gastric bypass has been found to be feasible, but this procedure in case of prior VBG is deemed both challenging and difficult and should be performed by experienced surgeons (Obes Surg 22:1554–1561, 2012; Surg Endosc 27:558–564, 2013)., Materials and Methods: We present the case of a 56-year-old man with a body mass index (BMI) of 39.6 kg/m2 who had undergone open VBG, 11 years ago (initial BMI 39.2 kg/m2). He was referred to our tertiary care center for weight regain and daily vomiting., Results: In this high definition multimedia video, we present a step-by-step laparoscopic conversion of VBG to gastric bypass. After careful adhesiolysis, key points of such procedure are resizing of the small gastric pouch and resection of the enlarged gastric pouch with the band and the upper portion of the remnant fundus, in order to avoid leakage or blind stomach pouch. No adverse outcomes occurred during the postoperative period., Conclusion: Laparoscopic conversion of previous open VBG to gastric bypass is a challenging procedure. Learning the key points of such procedure is mandatory to limit postoperative complications.

Background: Although laparoscopic sleeve gastrectomy (LSG) was initially described as the first step of a 2-stage procedure for high-risk patients requiring laparoscopic Roux-en-Y gastric bypass (LRYGB), it is now being used as a single-stage procedure. Experience with laparoscopic bariatric surgery is growing, such that LRYGB is increasingly feasible for patients with body mass index (BMI) ≥ 50 kg/m². Nevertheless, outcomes for such category of patients following LSG and LRYGB are lacking., Objective: To compare weight loss and changes in obesity related co-morbidities at one year following LSG with LRYGB in patients with BMI ≥ 50 kg/m²., Settings: The prospective database of a single surgery university center was queried for clinical and other relevant data., Methods: From January 2004 to January 2013, 74 and 285 patients underwent LSG or LRYGB with a BMI ≥ 50 kg/m². At one year, rate of follow-up was 92.8%. Success of surgery was defined as % of excess weight loss (%EWL)≥ 50% at one year. Logistic regression was used to compute odds ratio (OR) to evaluate the success at one year of surgery., Results: LSG (N = 74) and LGBP (N = 285) groups did not differ for initial BMI (57.2 ± 7.1 versus 56.7 ± 5.5 kg/m²; P = .52), % of female (64.6% versus 73.7%, P = .13) or major adverse postoperative events (5.7% versus 6.7%; P = .85). At one year, the mean percentage of weight loss (%) (22.0 ± 7.6 versus 30.3 ± 7.4; P < .0001) and percentage of excess weight loss (%) (40.2 ± 15.2 versus 55.0 ± 14.6; P < .0001) and rates of remission of diabetes (47.5% versus 70.7%; P = .01) were greater in the LGBP than LSG group. In multivariate analyses (OR), LSG was an independent factor of failure of weight loss (.12; P < .0001) CONCLUSION: After 1 year of follow-up in patients with a BMI ≥ 50 kg/m², LRYGB provides better weight loss and resolution in diabetes than LSG with similar postoperative morbidity. Further long-term studies are needed to confirm these results., (Copyright © 2015 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)