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Background Endoscopy plays a pivotal role in the management of adverse events (AE) following bariatric surgery. Leaks, fistulae, and post-operative collection after sleeve gastrectomy (SG) may occur in up to 10% of cases. Objectives To evaluate the efficacy and safety of endoscopic internal drainage (EID) for the management of leak, fistula, and collection following SG. Setting Retrospective, observational, single center study on patients referred from several bariatric surgery departments to an endoscopic referral center. Methods EID was used as first-line treatment for the management of leaks, fistulae, and collections. Leaks and fistulae were treated with double pigtail stent (DPS) deployment in order to guarantee internal drainage and second intention cavity obliteration. Collections were treated with endoscropic ultrasound (EUS)–guided deployment of DPS or lumen apposing metal stents. Results A total of 617 patients (83.3% female; mean age, 43.1 yr) were enrolled in the study for leak (n = 300, 48.6%), fistula (n = 285, 46.2%), and collection (n = 32, 5.2%). Median follow-up was 19.5 months. Overall clinical success was 84.7% whereas 15.3% of cases required revisional surgery after EID failure. Clinical success according to type of AE was 89.5%, 78.5%, and 90% for leak, fistula, and collection, respectively. A total of 10 of 547 (1.8%) presented a recurrence during follow-up. A total of 28 (4.5%) AE related to the endoscopic treatment occurred. At univariate logistic regression predictors of failure were: fistula (OR 2.012), combined endoscopic approach (OR 2.319), need for emergency surgery (OR 1.755), and previous endoscopic treatment (OR 4.818). Conclusion Early EID for the management of leak, fistula, and post-operative collection after SG seems a safe and effective first-line approach with good long-term results.

Laparoscopic sleeve gastrectomy (LSG) modifies gastrointestinal substances that control hunger and satiation via the brain-gut axis. A potential mechanism implicated in weight loss is the shift in food preferences. Our aim was to assess changes in taste preferences and their relationship to weight loss. This is a prospective longitudinal observational study in 100 consecutive LSG patients. Questionnaire with photographs of tastes was administered before surgery, at postoperative (PO) day 6 and PO month 6. Participants asked to rate each item in terms of desire to consume on a 5-point Likert scale. Preoperative demographics are as follows: 77 women/23 men, mean age 40.8 ± 12 years, and mean BMI 42.46 ± 6.7 kg/m2. Mean 6-month PO % total body weight loss (%TBWL): 24 ± 6.2%. Preferences for bitter, salty, umami, fatty, sour, spicy, and sweet decreased significantly from baseline to PO day 6 (p

Background Roux-en-Y gastric bypass procedure is an effective treatment for morbid obesity. One of the most frequent complications after this operation is the appearance of a gastrojejunal anastomotic stricture. Mechanisms underlying the development of such complication are unclear. Objective: The aim of the present retrospective study was to compare the rates of gastrojejunostomy stricture between the antecolic and retrocolic technique in a large cohort of patients undergoing Roux-en-Y gastric bypass for morbid obesity, with the same gastrojejunal anastomotic technique. Setting University Hospital, France. Methods From November 2000 to March 2012, 1500 patients underwent laparoscopic Roux-en-Y gastric bypass. The antecolic and the retrocolic technique were used in respectively 572 and 928 consecutive patients. All procedures were performed using a circular stapled gastrojejunostomy and absorbable sutures. Results There was no significant difference with respect to gender, age, body mass index, and obesity related co-morbidities between both groups. Patients were followed for 24–146 months (mean 67.5 mo). Fifty-one patients developed a gastrojejunal stricture (3.4%), 37 in the antecolic group (6.5%) and 14 in the retrocolic group (1.5%). The difference was significant ( P .0001). The mean time to onset of gastrojejunal stricture symptoms after surgery was 1 month, ranging from 1 to 3 months. All patients were successfully treated using Savary-Gilliard dilatators. All patients with a gastrojejunal stricture were followed up for a minimum of 36 months. No recurrence was observed and no revisional surgery was needed. Weight loss was similar in patients who developed an anastomotic stricture compared with those without stricture. In the antecolic group internal hernia occurred in 12 of the 110 with no closure of mesenteric defects and in 8 of the 462 (1.7%) with defects closed. In the retrocolic group, 11 patients (1.2%) developed an internal hernia. Conclusions A significant lower gastrojejunal stricture rate was observed in the retrocolic group, with no increased risk of internal hernia, when mesenteric defects were closed. The antecolic technique seems to be a risk factor for gastrojejunal stricture development after laparoscopic gastric bypass.

Perioperative complications following bariatric surgery (BS) have been poorly analysed and their management is not clearly assessed. The associated frequency of ICU admission is difficult to estimate. Among surgical complications, digestive perforations are the most frequent. The most common postoperative complications of sleeve gastrectomy are fistulas, but bleeding on the stapling line is also commonly reported. Complication rates are higher after Roux-en-Y gastric bypass, mainly due to anastomotic leaks. Medical complications are mainly thromboembolic or respiratory complications. All these surgical and medical complications are not easily detected; clinical signs can be atypical or insidious, often resulting in delayed management. Respiratory signs can be predominant and lead erroneously to pulmonary or thromboembolic diseases. Diagnostic criteria are based on minor clinical signs, tachycardia being probably the most frequent one. Lately, complications are revealed by haemodynamic instability, respiratory failure or renal dysfunction and radiographic findings. Management decision according to these abnormal signs is based on a combined multidisciplanary approach including surgical and/or endoscopic procedures and medical care, depending on the nature and severity of the surgical complication. Medical management is based on supportive ICU care of organ dysfunctions, curative anticoagulation if required, nutritional support, and appropriate anti-infective therapy. Pharmacological data are limited in morbidly obese patients and the appropriate doses are debated, especially for anti-infective agents. Complicated BS cases have a poor outcome, probably largely related to delayed diagnosis and reoperation.

Marginal ulcer can be a serious complication after laparoscopic gastric bypass surgery. The aim of this study was to compare the rates of marginal ulcer between the antecolic and the retrocolic technique, in a large cohort of patients.Over a near 10-year period, 1,142 patients underwent laparoscopic gastric bypass surgery. The antecolic and the retrocolic technique were used in respectively 572 and 570 consecutive patients. All procedures were performed using a circular stapled gastrojejunostomy.Patients were followed for 18 to 99 months (mean 48.8 months). During follow-up, 46 patients developed a marginal ulcer (4 %), 32 in the antecolic group (5.6 %) and 14 in the retrocolic group (2.5 %). Nineteen patients (3.3 %) in the antecolic group and eight patients in the retrocolic group (1.4 %) developed early marginal ulcer (i.e., within 3 months after surgery). The mean time to onset of anastomotic ulcer symptoms after surgery was 11 months (range 0.25-72). Forty-four patients were submitted to medical treatment, and 35 patients (79.5 %) had complete resolution of their symptoms.Patients with an antecolic Roux limb develop significantly more marginal ulcers (p = 0.007) and early marginal ulcer (p = 0.033) than the patients with a retrocolic Roux limb. The antecolic technique seems to be a risk factor for appearance of marginal ulcer.

Gastrointestinal complications after laparoscopic Roux-en-Y gastric bypass (LRYGBP) are not uncommon. Leakage of the gastro-jejunal anastomosis is the main early surgical complication of LRYGBP. Hepatic portal venous gas (HPVG) has been described in association with a variety of pathologic conditions. HPVG is a potentially life-threatening condition due to its etiology, with a global survival rate of

Fig 2. Abdominal computed tomography with oral and intravenous contrast agent showing gastric-pouch dilation caused by agar-agar bezoar and presence of the contrast agent in the small bowel (coronal plane). We present the case of a 64-year-old female patient who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) in 2010 for morbid obesity. Her body mass index (BMI) decreased from 38 to 21 kg/m without any postoperative complication. She consulted the emergency department in April 2015 for nausea, vomiting, and dysphagia over 72 hours, since ingestion of an agar-agar– based dessert. Presuming that agar-agar was biodegradable, the patient was reassured by the emergency physician and

Several database studies report a lack of care in elderly patients with colorectal cancer.To describe the management of elderly patients admitted for colorectal cancer; to identify factors associated with standard management according to recommendations and to study factors influencing the survival.All consecutive patients over 75 years managed for a colorectal adenocarcinoma in our hospital from 1995 to 2000 and followed until 2006 were retrospectively included. The appropriateness of the management of their disease according to the recommendations available at that time was assessed. Several risk factors in receiving the standard cancer treatment were tested using univariate and then multivariate logistic regression. Risk factors of survival were studied using univariate and then multivariate survival analysis.One hundred and ten patients were included. Median age was 82 years (range: 75-96). A surgical treatment was performed in 96 patients. The median overall survival was 32 (1-108) months. A standard cancer treatment according to recommendations was performed in 53 (48%) patients: adjuvant chemotherapy in 6/23 patients with stage III tumour, palliative chemotherapy in 3/18 patients with stage IV tumour and adjuvant radiotherapy in 4/14 patients who had a rectal tumour resection. Multivariate analysis retains tumour stage I or II (OR=7.6, 95% C.I.=[2.9-19.9], p0.0001) as the only factor associated with standard treatment and presence of metastasis (HR=3.9, 95% C.I. [1.4-10.8], p=0.005), and Charlson's score3 (HR=28.9, 95% C.I. [2.5-335.6], p=0.001) as independent risk factors of poor survival.Fifty two percent of elderly patients have had a sub-standard cancer treatment. The majority had a surgical treatment, but only a few received chemotherapy or radiotherapy. Metastasis, older age and Charlson's comorbidity score are the main prognosis factors of poor survival.

Vertical banded gastroplasty (VBG) was the restrictive procedure of choice for many years. However, VBG has been associated with a high rate of long-term failure. We reviewed our experience of conversion of failed VBG to Roux-en-Y gastric bypass (RYGBP). The data on all patients undergoing conversion of failed VBG to RYGBP were reviewed. Failed VBG was defined as insufficient weight loss (BMI > 35 kg/m2) and/or VBG-related complications. We performed 24 conversions from VBG to RYGBP. Median age was 40 ± 8 years (range 28 to 61). Preoperative weight was 111 ± 25 kg (range 85 to 181), and median BMI was 41 ± 8 kg/m2 (range 30 to 69 kg/m2). Indication for conversion was: VBG failure in 18 patients and VBG complications in 6 patients. A gastrectomy (total or proximal) had to be performed in 5 cases (21%). The conversion was performed by laparoscopy in 13 cases. Postoperative complications occurred in 4 patients (16.7%). There were no leaks, nor mortality. Postoperative BMI was 31 kg/m2 (range 25 to 42) at a median follow-up of 12 months (range 3 to 36 months). The average percentage of excess weight loss was 62% at 1 year. VBG has been associated with a significant reoperation rate for failure and/or complications. Conversion to RYGBP is effective in terms of weight loss and treatment of complications after VBG. Gastrectomy and resection of the staple-line could reduce such complications as leaks and mucocele. Although technically challenging, conversion of VBG to RYGBP is feasible, with acceptable morbidity and no mortality. The conversion is feasible laparoscopically.

To report the prognosis and management of patients reoperated for severe intraabdominal sepsis (IAS) after bariatric surgery (S0) and admitted to the surgical intensive care unit (ICU) for organ failure.A French observational study in a 12-bed adult surgical intensive care unit in a 1,200-bed teaching hospital with expertise in bariatric surgery. From January 2001 to August 2006, 27 morbidly obese patients (18 transferred from other institutions) developed severe postoperative IAS (within 45 days). Clinical signs, biochemical and radiologic findings, and treatment during the postoperative course after S0 were reviewed. Time to reoperation, characteristics of IAS, demographic data, and disease severity scores at ICU admission were recorded and their influence on prognosis was analyzed.The presence of respiratory signs after S0 led to an incorrect diagnosis in more than 50% of the patients. Preoperative weight (body mass index [BMI]50 kg/m2) and multiple reoperations were associated with a poorer prognosis in the ICU. The ICU mortality rate was 33% and increased with the number of organ failures at reoperation.During the initial postoperative course after bariatric surgery, physical examination of the abdomen is unreliable to identify surgical complications. The presence of respiratory signs should prompt abdominal investigations before the onset of organ failure. An urgent laparoscopy, as soon as abnormal clinical events are detected, is a valuable tool for early diagnosis and could shorten the delay in treatment.

Background: The outcomes and initial results of laparoscopic sleeve gastrectomy were evaluated. Methods: A prospective study of the initial 10 patients who underwent laparoscopic sleeve gastrectomy (LSG) was performed. Study endpoints included operative time, complication rates, hospital length of stay and percentage of excess weight loss (%EWL). Results: There were 5 women and 5 men, with mean age 43 years (range 31 to 52). Mean preoperative weight was 182 kg (range 125-247 kg), with mean preoperative BMI 64 (range 61-80). Indication for LSG was related to BMI in all patients. 1 patient had previous restrictive bariatric surgery. Mean operative time was 2 hours (range 1.5-2.5). No patient required conversion. There were no postoperative complications nor mortality. Median hospital stay was 7.2 days. Average %EWL and BMI at 1 year were 51% and 23 kg/m2, respectively. Conclusion: LSG can be safely integrated into a bariatric surgical program with good results in terms of weight loss and quality of life. LSG can be a firststage procedure before gastric bypass or duodenal switch or a one-stage restrictive procedure if longterm results are good. LSG should be considered as a surgical option in the bariatric field.

Background: Controversy exists regarding the best surgical treatment for super-obesity (BMI >50 kg/m 2 ). The two most common bariatric procedures performed worldwide are laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGBP). We undertook a retrospective single-center study to compare the safety and efficacy of these two operations in super-obese patients. Methods: 290 super-obese patients underwent laparoscopic bariatric surgery: 179 LAGB and 111 LRYGBP. Results: There were one death in both groups. The early complication rate was higher in the LAGB group (10% vs 2.8%, P

Background: The feasibility and outcomes of conversion of laparoscopic adjustable gastric banding (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGBP) was evaluated. Methods: From November 2000 to March 2004, all patients who underwent laparoscopic conversion of LAGB to LRYGBP were retrospectively analyzed. The procedure included adhesiolysis, resection of the previous band, creation of an isolated gastric pouch, 100-cm Roux-limb, side-to-side jejuno-jejunostomy, and end-to-end gastro-jejunostomy. Results: 70 patients (58 female, mean age 41) with a median BMI of 45±11 (27-81) underwent attempted laparoscopic conversion of LAGB to an RYGBP. Indications for conversion were insufficient weight loss or weight regain after band deflation for gastric pouch dilatation in 34 patients (49%), inadequate weight loss in 17 patients (25%), symptomatic proximal gastric pouch dilatation in 15 patients (20%), intragastric band migration in 3 patients (5%), and psychological band intolerance in 1 patient. 3 of 70 patients (4.3%) had to be converted to a laparotomy because of severe adhesions. Mean operative time was 240±40 SD min (210-280). Mean hospital length of stay was 7.2 days. Early complication rate was 14.3% (10/70). Late major complications occurred in 6 patients (8.6%). There was no mortality. Median excess body weight loss was 70±20%. 60% of patients achieved a BMI of

Postoperative rhabdomyolysis is an uncommon event. The aim of this study was to determine the incidence of rhabdomyolysis following laparoscopic obesity surgery.Rhabdomyolysis was studied prospectively. Over a 6-month period, 66 consecutive patients underwent bariatric surgery (gastric banding (n=50) and gastric bypass (n=16)). All patients underwent laparoscopic procedures. A range of blood tests, including serum creatine phosphokinase (CPK) level and serum creatinine, were systematically performed before surgery, and on the first and third day postoperatively. Rhabdomyolysis was defined as a postoperative CPK level1050 IU/L.Serum CPK was noted to increase significantly postoperatively to1050 units in 3 patients (6%) in the adjustable banding group and 12 patients (75%) in the gastric bypass group (P0.01). In the bypass group, 4 patients (25%) had a serum CPK level10000 IU/L, but there were none in the gastric banding group. All patients with CPK level10000 IU/L had BMI60 kg/m(2). No patients experienced acute renal failure.Rhabdomyolysis occurred in 22.7 % of 66 consecutive patients undergoing laparoscopic bariatric surgery. Risk factors were identified: massive obesity and long duration of the operation. Early diagnosis may have significant impact on outcome by preventing or reducing the severity of complications from rhabdomyolysis. CPK level should be performed systematically after obesity surgery.

Background Candida peritonitis (CP) is generally considered to be a severe disease, but its impact on outcome in critically ill patients remains unknown. Hypothesis The predictive factors of mortality due to CP can be determined by study of a population of patients with CP. Design A retrospective review of a prospective surgical intensive care unit (ICU) database of patients (January 1, 1994, through December 31, 2000). Setting University hospital in Paris, France. Patients Eighty-three patients with generalized CP. Main Outcome Measures Demographic and microbiologic data and outcome were collected, and nonsurvivors were compared with survivors. Results Overall ICU mortality due to CP was 43 (52%) of 83 patients. In a stepwise multivariate logistic regression, the following 4 variables were independently associated with mortality: APACHE II (Acute Physiology and Chronic Health Evaluation II) score on admission of at least 17 (odds ratio [OR], 28.4; 95% confidence interval [CI], 5.7-142.5; P P = .003), upper gastrointestinal tract site of peritonitis (OR, 7.7; 95% CI, 1.7-34.7; P = .007), and results of direct examination of peritoneal fluid that were positive for Candida (OR, 4.7; 95% CI, 1.2-19.7; P = .002). Conclusions These results confirm the severity of CP in ICU patients and emphasize the prognostic value of direct examination of peritoneal fluid for Candida in this context.