Search

Obesity is frequently associated to many functional gastrointestinal disorders. The aim of the present study was to assess the prevalence of functional gastrointestinal disorders in obese patients, according to their body mass index and their recruitment source. Five hundred ninety-six obese patients (body mass index (BMI) > 30) filled out a standard questionnaire in order to evaluate the presence of functional gastrointestinal disorders. They were divided into four groups according to the Rome III criteria and their BMI: OF, obese patients from functional gastrointestinal disorder (FGID) enrollment; OO, obese patients from obesity management enrollment; MF, morbid obesity patients from FGID enrollment; and MO, morbid obesity patients from obesity management enrollment. Data analysis was performed using multivariate logistic regression. Out of the 596 obese patients included in the present study, 183 (33 %) were complaining of FGIDs, while 413 (67 %) were consulting for obesity management. Compared to the OF group, the OO patients had a higher prevalence of females (P = 0.008) and a younger age (P

The efficacy and safety of bariatric surgery have been poorly studied in patients affected with HIV. Although sleeve gastrectomy (SG) is the most widely used procedure in many countries, most of the published literature reported results with the gastric bypass (GBP) procedure on morbidly obese HIV patients.We have evaluated retrospectively, in eight consecutive patients who underwent a SG, its effect in weight loss and its impact on the treatment and on the markers of HIV infection.Seven out of eight patients were females. The mean age was 46 years, with a median preoperative BMI of 42 kg/m(2). The mean duration of HIV infection and CD4 cell count were 13.4 years and 457 cells/mm(3), respectively. The mean weight loss was 37 kg in 20 months, the excess BMI loss was 80.8 ± 30.9 %, and the excess weight loss is 81.5 ± 28.9 % with one minor complication. CD4 counts were unchanged. Three patients had therapy modifications that were unrelated to bariatric surgery. Two patients had a therapeutic drug monitoring before and after the intervention. Plasma concentrations remained in therapeutic levels after the SG. Most comorbidities disappeared postoperatively, decreasing the cardiovascular risk.The sleeve gastrectomy was safe and effective with no consequences on CD4 counts and viral load in HIV-affected obese patients. It should be considered as a part of the treatment in morbidly obese HIV patients.

Identifying factors that influence weight loss after bariatric surgery is one way to predict a successful surgical outcome. Knowledge of the effect of gender on weight loss after bariatric surgery has not been well demonstrated in the literature despite being noted in every day practice. The aim of this study was to find the influence of gender on long-term weight loss after bariatric surgery.A retrospective analysis of data retrieved from a prospectively maintained bariatric database was conducted.The study included 640 consecutive patients. Their mean age was 38 ± 10 years, mean preoperative body mass index was 44.9 ± 8.4 kg/m2, and mean preoperative excess weight (EW %) was 108.3 ± 38.4%. The mean of the average excess weight loss (EWL %) was 43.3 ± 42.4%. Three procedures were utilized: Roux-en-Y gastric bypass (RYGB), vertical banded gastroplasty (VBG), and gastric banding (GB). Both VBG and RYGB induced significantly more EWL % than GB (d = 22.1%, p0.001 and d = 16, p = 0.02, respectively). In patients who underwent VBG and GB, males had significantly lower preoperative EW % (Student t = -4.86, p0.001, and Student t = 4.69, p0.001, respectively), and postoperative mean of the average EWL % (Student t = -2.43, p = 0.016, and Student t = -3.33, p = 0.002, respectively) than females. In patients who underwent RYGB, there were no differences in the preoperative EW % (t = -1.03, p = 0.309) or the mean of the average EWL % (t = 0.406, p = 0.688). The simple linear regression model used to explain the variability in EWL %, accounted for by the variability in the preoperative EW %, was significant (F = 180, p0.001). Analysis of the residual errors in predicting the EWL % revealed no significant difference between males and females after VBG and after RYGB (t = 0.117, p = 0.907 and t = 1.052, p = 0.3, respectively), while it was significant after GB (t = -2.999, p = 0.003).From our experience, we suggest that GB not to be offered as a first choice for obese male patients.

We welcomed with great interest the masterpiece of Nedelcu et al. [1] concerning the outcome of leaks after laparoscopic sleeve gastrectomy (LSG) based on a new algorithm addressing leak size and gastric stenosis. The article stressed the importance of adopting this new algorithm in order to standardize leak management, thus reducing the number of endoscopic procedures. We agree with the authors about the use of endoscopic internal drainage (EID) by means of double pigtail to achieve complete healing. As already reported by our team [2], since March 2013, we adopted EID as the only endoscopic treatment in case of fistulas after LSG or gastric bypass, irrespective to leak size. Moreover, we believe in the importance of introducing a well-defined algorithm in order to standardize the endoscopic treatment modality for leak following bariatric surgery. However, according to our experience, we have some remarks to do. Here, we report a case of a 59-year-old woman, presenting an early fistula [3] following laparoscopic sleeve gastrectomy. At day 12 after surgery, she underwent reoperation for peritonitis with lavage and drainage of peritoneal cavity, and two peri-gastric surgical drainage were left in place. No primary repair was attempted due to severe local tissue inflammation. Endoscopy showed a 2-cm-long dehiscence, of the last staple fire line, allowing passing through with the scope. Swallow study through the scope showed the persistence of intra-abdominal collection in the left hypochondrium and the presence of a left bronchial tree fistula (Fig. 1). EID was performed and two 10 Fr double pigtail drains (DPD) were positioned with the aim to drain and promote re-epithelialization of the cavity. After four endoscopic sessions, an Ovesco® clip (OTSC®; Ovesco Endoscopy GmbH, Tubingen, Germany) was delivered to close the remaining blind cross-fistula.

Obesity is considered as a risk factor for many functional digestive disorders. The aim of the present study was to evaluate the prevalence and the association of functional digestive symptoms affecting the upper and the lower digestive tract in patients eligible for bariatric surgery.Before surgery, 120 consecutive patients with normal upper endoscopy (7.5% males, mean BMI 44 ± 6 m/kg(2)) have filled a standard questionnaire in order to evaluate the presence of depressive symptoms and functional digestive disorders according to the Rome criteria. The major symptoms (esophageal, gastroduodenal, anorectal, and abdominal pain) were coded as dichotomous variables. Data analysis was performed using multivariate logistic regression with a backwards selection procedure adjusted only for the variables that were significant in univariate analysis (p 0.05).Functional symptoms were present in 89% of the subjects (2.5 functional digestive symptoms/subject). Depression symptoms were found in 43% of the patients. Esophageal symptoms were independent predictors for the presence of gastric, bowel, and anorectal symptoms. Functional abdominal pain and bowel symptoms were present, respectively, in 19% and 84% of the patients. Approximately half of the patients have specific functional bowel disorders (28.6% constipation, 18% irritable bowel syndrome, 18% diarrhea, 1% bloating) and 35.7% have non-specific bowel disorders. Anorectal symptoms were found in 40% of the patients: difficult defecation in 32% and fecal incontinence in 9.8% of the patients. Depression was an independent predictor for anorectal symptoms.This study shows the high prevalence of functional bowel symptoms in patients complaining of morbid obesity.

Intragastric balloon (IGB) is one of the available options for the management of morbid obesity. The procedure is generally safe and of moderate efficacy in most of the cases. One of the reported complications of IGB is gastric perforation. The management of this complication is classically surgical. To our knowledge, conservative management for gastric perforation secondary to IGB has not been reported. A 27-year-old female patient presented with sudden abdominal pain in the left upper quadrant, 2 months after having an IGB placed. The provisional diagnosis was gastric perforation. Balloon extraction was performed and a conservative management of the gastric perforation was pursued successfully. We therefore propose that this sort of management might be adopted in carefully selected cases.

Morbidly obese patients have a high prevalence of known and unknown cardiopulmonary diseases. The aim of this study was to assess the value of cardiopulmonary tests routinely performed before bariatric surgery.The population studied included 67 women and 10 men, aged 39 +/- 10 years, with a body mass index of 43 +/- 4 kg/m2. All patients, candidates for laparoscopic gastric banding, underwent after clinical evaluation: resting electrocardiography (ECG), Doppler-echocardiography, exercise stress testing, Epworth Sleepness Scale, and polysomnography, spirometry, blood gases, and chest x-ray.The ECG demonstrated conduction or ST-T wave abnormalities in 48 patients (62%). Prolongation of the QT interval10% was found in 13 patients (17%). Stress tests were negative in 56 patients (73%) and were not interpretable in the remaining 21 patients (27%). Doppler-echocardiography showed hypertrophy of the left ventricular posterior wall in 47 patients (61%) without any consequences on perioperative management. Polysomnography showed an obstructive sleep apnea-hypopnea syndrome (OSAHS) in 31 patients (40%), leading to preoperative continuous positive airway pressure (CPAP) treatment in 17 patients (22%). Nevertheless, the Epworth Sleepness Scale was pathological in only 17 patients (22%). Ten patients (13%) presented minor chest x-ray alterations. Spirometry demonstrated an obstructive respiratory syndrome in 13 patients (17%) and a restrictive syndrome in five patients (6%). Hypoxemia80 mmHg was observed in 21 patients (27%) and hypercapnia45 mmHg in six patients (8%), without any consequences on the management of the perioperative period.We recommend the preoperative assessment by clinical evaluation, ECG, and polysomnography. For patients with cardiac or pulmonary histories and/or ECG abnormalities, we recommend echocardiography, spirometry, and blood gases.

The aim was to assess the value of treament of inguinal hernias by a totally extraperitoneal laparoscopic route. Between January 1993 and December 1998, 541 patients (490 men, 51 women) with 757 hernias were operated laparoscopically by a totally extraperitoneal route. Whenever the parietal repair required the insertion of a prosthesis, this was the method chosen. The procedure was perfomed under general anesthesia. One or two polypropylene prostheses of 15 × 12 cm were placed at the deep aspect of the abdominal wall, split but not fixed. The patients were followed up at one, six and twelve months and then annually. The mean operation time decreased with experience, from 66 minutes in 1993 to 47 minutes in 1998 for unilateral hernias and from 104 to 71.5 minutes for bilateral cases. The laparotomy conversion rate was 2%. Mortality was nil. Morbidity was as follows: hemorrhagic scrotal extravasations 10%, serous effusions 3.5%, phebitis 0.3%, pneumopathies 0.3%. The mean period of hospitalization was 2.9 days and the global recurrence rate was 0.6% (4 cases in the first year, 1 case at three years). The totally extraperitoneal laparoscopic route seems to be the method of choice for the treatment of inguinal hernias requiring a prosthesis. It reduces hospital stay and allows earlier return to work and is associated with only minor morbidity and a low recurrence rate.

The principle of parietoscopy is the creation of a subcutaneous plane of cleavage in front of the aponeuroses by insufflation of CO2. The aim is the repair of certain hernias and incisional hernias of the abdominal wall without damaging the overlying skin, mainly for cosmetic reasons, especially in young women. In our series access was suprapubic or umbilical depending on the site of the lesion to be repaired. A 10 mm blunt tip trocar was placed in contact with the aponeurotic plane. After initial separation of the subcutaneous tissue, progressive insufflation of CO2 stripped the cutaneous layer extensively upwards and laterally. Using one or two 5 mm trocars, the aponeurotic layer was progressively freed and the affected zones identified. These were repaired by standard endoparietal sutures or by percutaneous sutures using a Reverdin needle. Fifteen patients (14 women and 1 man) with a mean age of 30 years (range 19 to 35) with diastasis of the rectus abdominis muscles (5 cases), incisional hernias (3 cases) or an epigastric or linea alba hernia (7 cases) were treated by parietoscopy. Conversion to a classical approach was necessary in one man with diastasis of the rectus muscles because fibrosis prevented a subcutaneous plane of cleavage. Repair was possible in 14 cases. The mean operative duration was 1h 20 min and that of hospitalisation was 2 days (1–3). There was no mortality or morbidity. The mean follow-up was 18 months (4–40) with excellent cosmetic and functional results. Thus, abdominal parietoscopy allows repair of certain minor parietal lesions with preservation of the overlying skin. Its indications are of a cosmetic nature, in young women with normal skin overlying an abdominal wall defect.

In a prospective randomized trial comparing a totally pre-peritoneal (TPP) laparoscopic approach and the Stoppa procedure (open), 100 patients with inguinal hernias (Nyhus IIIA, IIIB, IV) were followed over a 3-year period. Both groups were epidemiologically comparable. In the laparoscopic group, operating time was significantly longer (p=0.01) but hospital stay (3.2 vs 7.3 days) and delay in return to work (17 vs 35 days) were significantly reduced (p=0.01). Post operative comfort (less pain) was better (p=0.001) after laparoscopy. In this group, morbidity was also reduced (4% vs 20%, p=0.02). The mean follow up was 605 days and 93% of the patients were reviewed at three years. There were three (6%) recurrences after TPP, especially at the beginning of the surgeon's learning curve versus one for the Stoppa procedure (ns). For bilateral hernias, the authors suggest the use of a large prosthesis rather than two small ones to minimise the likelihood of recurrence. In the conditions described the laparoscopic (TPP) approach to inguinal hernia treatment appears to have the same long-term recurrence rate as the open (Stoppa) procedure, but confers a real advantage in the early post operative period.