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Situation La gastrectomie longitudinale ou sleeve gastrectomie (SG) est de plus en plus choisie comme traitement chirurgical de l’obesite morbide. Cela en raison de son efficacite et de son taux acceptable de complications. A long terme, la dilatation de la poche gastrique peut entrainer une stagnation de la perte de poids et une reprise ponderale.

Obesity is considered as a risk factor for many functional gastrointestinal disorders. The aim of the study was to evaluate if functional digestive disorders are associated with specific body mass index groups and gender.A total of 1074 patients (50.3 ± 16.5 years, 67 % females) filled out a standard Rome III questionnaire (79 % acceptance rate). The patients were assigned to five groups according to their body mass index: underweight (6 %), normal (49 %), overweight (28 %), obese (12 %), and morbidly obese (5 %). Data analysis was performed using multinomial logistic regression; subjects with the normal weight were the reference group.Patients presented specific demographic and clinical characteristics according to the weight groups. Underweight patients were younger (p0.001), and presented a female predominance (p = 0.006), dysphagia (p = 0.013) and soiling (p = 0.021). Overweight patients were older (p = 0.001), and reported more frequently globus (p = 0.001), regurgitation (p = 0.004), postprandial distress syndrome (p = 0.009). Obese patients reported more frequently regurgitation (p0.001). Morbid obese patients reported dyspepsia (p = 0.046). In patients, the odds of regurgitation increased with body mass index from underweight to obesity, but not when compared to morbid obesity. The probability of globus and regurgitation increased with body mass index and presented a steeper increase in females.In patients with functional gastrointestinal disorders, globus and regurgitation are associated with body mass index, mainly in female patients.

Aim of the study Prospective evaluation of the quality of life of patients after laparoscopic fundoplication for gastroesophageal reflux disease (GERD). Patients and methods The quality of life of 30 consecutive patients who underwent laparoscopic fundoplication was evaluated using the GIQLI (gastrointestinal quality of life index) questionnaire, which included 36 items in five different areas: digestive symptoms, physical condition, emotional reaction, social integration and medical treatment. Seventeen men and 13 women (mean age: 50.2 +/- 17 years (32-68) were included with a follow-up of at least 1 year and with complete data available. The quality of life was evaluated before surgery, and at 1 month, 3 months, 6 months and 1 year after surgery with a 100% follow-up. Thirty healthy volunteers representing an identical population (with respect to age, sex, BMI, profession, smoking, etc.) anonymously filled in the same questionnaire. The pre- and postoperative GIQLI scores of patients operated for GERD were compared with the GIQLI score of the control group. Results Preoperatively, the GIQLI score (87 +/- 9.5) was much lower than that of the control group (123.4 +/- 13.6) (p Conclusion The quality of life of patients after laparoscopic antireflux surgery was greatly improved and was close to the level expected in an healthy population. However, the study demonstrated the possible presence of postoperative functional digestive disorders, although these symptoms were not considered as being uncomfortable, since the level of satisfaction was 96.6% (n = 29).

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 classic treatment of generalized peritonitis due to perforation of sigmoid diverticula is based on the principle of a two-stage surgery with a temporary derivation of the colonic transit. This procedure is associated with a prohibitively high immediate and delayed morbidity, especially associated with the abdominal wound. The laparoscopic approach to this complication is less aggressive and allows a second-stage elective laparoscopic resection. Eighteen consecutive patients (ten women and eight men; average age, 53.7 years) underwent emergency laparoscopic treatment for generalized peritonitis due to perforated diverticula. Eight of these patients had previously had diverticulitis attacks. By peritoneal cavity exploration and full peritoneal lavage (average, 15 L), the infected sigmoid lesion was stuck with biologic glue. A drain was inserted at the site of the lesion and in some cases also in other abdominal zones. No colostomy was necessary. Antibiotic treatment was started at diagnosis and continued for a minimum of 7 days. There was no mortality. Morbidity was limited to three patients (two cases of lymphangitis and one of pulmonary disease). No patient had a wound abscess or residual deep collections. The mean hospitalization was 8 days. Fourteen patients underwent elective laparoscopic sigmoid resection with a delay of 3.5 months. One conversion to laparotomy was necessary. The laparoscopic treatment of generalized peritonitis due to perforated sigmoid diverticula is an interesting alternative to the traditional treatment. It is associated with a lower morbidity, a shorter postoperative hospital stay, and an improvement in the patient's quality of life, because colostomy is avoided. It is also associated with economic savings.

Learning curve and experience in laparoscopic treatment of gastroesophageal reflux disease. Study aim: Laparoscopic treatment of gastroesophageal reflux disease (GERD) by partial (PF) or total (TF) fundoplication is the most appropriate surgical treatment after failure of medical treatment. The aim of this study was to compare the results of the same series in three consecutive periods in order to determine the effects of the learning curve and experience on the technique and outcome. Patients and methods: From January 1993 to January 1998, 150 patients (84 men and 66 women) with a mean age of 52.2 years (18 to 78) were included. Three groups of 49, 50 and 51 patients were chronologically defined. The comparison was established on the following criteria: the operative technique; the conversion rate; the mortality and morbidity rate; the duration of surgery and hospitalization and the results with short and medium follow-up. Results: The three groups were comparable with respect to patients and GERD characteristics. One hundred and thirty two patients had a TF and 18 had a PF. Rossetti's type TF became the reference procedure (80,3% in group III) and closure of the diaphragmatic crura was performed systematically in group III (100%). The duration of surgery was significantly reduced between group I and the two other groups (138, 100, 80min). The rate of conversion decreased from 10,2% to 4% and then 0%. The average duration of hospitalization decreased from 5.8 to 4.2 days (p=0.01). There was no mortality and the morbidity rate decreased from 14,3% to 4% and then 0%. Seven cases of recurrence occurred(4.6%), 5 in group I (10,2%), 2 in group II (4%), and 0 in group III, (with a shorter follow-up). Conclusion: The effect of the learning curve has to be taken into account in the training of surgeons (within experienced departments, with «guidance» during initial interventions) and also in the evaluation of results, in order to allow a more accurate comparison between the different treatments for GERD.

Resume Situation En depit des progres recents de l'imagerie medicale, l'evaluation preoperatoire des tumeurs du foie, benignes ou malignes, peut manquer d'exactitude et de precision. Depuis le developpement de la chirurgie laparoscopique, les avantages de la laparoscopie diagnostique se sont associes a ceux de l'echographie operatoire. Objectif Le but de ce travail est de decrire la technique de l'echolaparoscopie du foie, de preciser ses applications et le role que l'association laparoscopie-echolaparoscopie peut avoir dans la localisation et la resecabilite des tumeurs hepatiques. Methodes Effectuee apres une exploration laparoscopique, l'echolaparoscopie du foie repose sur la reconnaissance des branches portales puis des veines sushepatiques. Pendant l'exploration vasculaire, le parenchyme hepatique est examine. Une mobilisation a minima de la sonde, a l'aide de mouvements de rotation horaire et antihoraire, permet une exploration complete du foie. Resultats L'association laparoscopie-echolaparoscopie permet de localiser avec precision les tumeurs hepatiques benignes ou malignes, et de faire des biopsies echoguidees. L'echolaparoscopie permet de decouvrir des petites lesions meconnues par l'imagerie preoperatoire. Elle etudie les rapports de la tumeur avec les vaisseaux adjacents et reconnait un thrombus portal. La resecabilite tumorale est precisee et le traitement chirurgical planifie. Conclusion L'association laparoscopie-echolaparoscopie du foie ameliore la selection des patients pouvant etre traites par resection hepatique, et permet de choisir puis de guider la resection la mieux adaptee.

Resume Objectif de l'etude L'objectif de ce travail etait d'evaluer la faisabilite de la cholangiographie peroperatoire (CPO) de routine lors des cholecystectomies laparoscopiques (CL) et d'apprecier son efficacite dans la detection des calculs de la voie biliaire principale (LVBP) et des plaies biliaires iatrogenes. Patients et methode De janvier 1991 a janvier 1999, 1 050 patients (âge moyen : 52,5 ans) ayant une lithiase vesiculaire symptomatique ou compliquee ont ete operes par laparoscopie. La CPO a ete tentee chez tous les patients avant la realisation de la cholecystectomie, avec une sonde ureterale de calibre 5 F, introduite dans le canal cystique, sous controle d'un amplificateur de brillance. Lorsqu'une une lithiase ou une plaie de la voie biliaire principale etait decouverte, son traitement etait systematiquement tente par laparoscopie. Resultats La CPO a ete realisee avec succes chez 840 patients (82,4 %). La duree moyenne de l'examen a ete de 15 minutes (7–45). Le taux de reussite a ete significativement plus eleve dans les lithiases vesiculaires simples (90,4 %), que dans les cholecystites aigues (61,9 %) (p = 0,01). Le taux d'echec a diminue avec l'experience passant de 23 % pour les 100 premieres tentatives a 1 % pour les 100 dernieres. Soixante-deux LVBP ont ete mises en evidence (7,4 %), dans 18 % des cas dans les cholecystites aigues et dans 4,6 % dans les lithiases vesiculaires simples. Dans 21 cas (33 %), il n'y avait aucun facteur predictif de LVBP. II y a eu 8 faux positifs (0,9 %). Sur les six plaies de la voie biliaire observees dans la serie (0,57 %), quatre sont survenues chez un patient ayant eu une CPO et deux ont ete reconnues et reparees immediatement. II n'y a pas eu de mortalite postoperatoire dans la serie. Conclusions La cholangiographie peroperatoire systematique est le meilleur procede de detection de la lithiase de la voie biliaire principale et semble influencer favorablement le pronostic des plaies iatrogenes de la voie biliaire principale quand elle permet leur detection peroperatoire et leur reparation immediate.

Objective: This study assessed the effectiveness of laparoscopic ultrasound in detecting main biliary duct stones. Methods: From November 1994 to August 1998, 600 patients treated by laparoscopic cholecystectomy were included in a prospective study, to compare intraoperative cholangiography and laparoscopic ultrasound. The biliary tree was successively explored by these two methods in the routine detection of common bile duct stones. Results: The feasibility of laparoscopic ultrasound was 100%. Cholangiography was performed only in 498 cases (83%). The time taken for laparoscopic ultrasound examination was significantly shorter (10.2 vs 17.9 min, P =0.0001). In this study, common bile duct stones were found in 54 cases (9%). For their detection, results were comparable to laparoscopic ultrasound and intraoperative cholangiography. For laparoscopic ultrasound, sensitivity was 80% and specificity 99%; and for cholangiography 75 and 98% respectively. Both examinations combined had a 100% sensitivity and specificity. Laparoscopic ultrasound failed to recognize the intrapancreatic part of the common bile duct in 78 cases (13%) and did not show anatomical anomalies detected by cholangiography. It did however detect other unsuspected intra-abdominal pathologies. Conclusions: Laparoscopic ultrasound is safe, repeatable, and non-invasive, but a considerable learning curve is necessary to optimize its efficacy. Comparison of relative cost must be undertaken.

Resume But de l'etude Cette etude retrospective a pour but de comparer deux series concomitantes de patients operes de hernie inguinale par la meme technique laparoscopique, l'une dans un centre hospitalo-universitaire de formation (CHU) et l'autre dans un centre prive, par un operateur unique ayant ete forme dans le meme CHU. Patients et methodes Cinq cent quarante et un patients ayant 757 hernies ont ete operes en six ans par voie laparoscopique totalement preperitoneale. Deux cent seize etaient traites au CHU par 48 operateurs (six seniors et 42 chirurgiens en formation) (groupe I) et 325 par un seul chirurgien exercant en pratique privee apres avoir ete forme dans le meme CHU (groupe II). Les deux groupes de patients etaient comparables de meme que le type de hernie. La technique operatoire a ete identique dans les deux groupes. La comparaison entre les deux groupes a porte sur: la duree operatoire, le taux de conversion, la duree d'hospitalisation, le taux de mortalite et de morbidite, le taux de recidive et les couts directs. Resultats Dans le groupe I, la duree operatoire a ete significativement (p = 0,01) plus longue pour les hernies unilaterales (68 vs 41 minutes) et bilaterales (108 vs 68 minutes) et n'a pas varie au cours des annees a la difference de celle du groupe II qui a diminue de 62 a 25 minutes dans les hernies unilaterales. Dans le groupe I, les complications peroperatoires ont ete plus frequentes, notamment l'ouverture du peritoine (28 % vs 3 %) (p = 0,001), la duree moyenne de sejour a ete significativement (p = 0,05) plus longue, en moyenne de 1,6 jour, le taux de morbidite a 30 jours a ete significativement (p = 0,01) plus eleve (16,2 % vs 4,9 %), et le cout de l'intervention a ete plus eleve en moyenne de 100 %. En revanche, il n'y a pas eu de difference significative entre les deux groupes en termes de mortalite (nulle), de taux de conversion (1,5 %), et d'incidence des recidives (1,3 % vs 0,6 %) (ns). Conclusion L'apprentissage du traitement laparoscopique des hernies de l'aine induit une operation plus longue, une hospitalisation plus longue, une morbidite plus elevee et un cout direct plus eleve. Apres une bonne formation initiale et avec une pratique reguliere, le chirurgien peut assurer le traitement laparoscopique des hernies de l'aine avec des resultats satisfaisants.

The aim of this study was to assess the risk of clinical thromboembolism in laparoscopic digestive surgery. From June 1992 to June 1997, 2,384 consecutive patients were studied. All received perioperative prophylaxis with low-molecular-weight heparin (LMWH), which was continued until full mobility was regained. Eight cases (0.33%) of deep venous thrombosis were noted, but there were no cases of pulmonary embolus. In six cases (five cholecystectomies with reverse Trendelenburg position and one inguinal hernia repair), release of the pneumoperitoneum took longer than 2 hours, and in two cases (one rectopexy and one sigmoid colectomy for diverticulitis), longer than 3 hours. In six of the eight cases, the diagnosis of DVT was made after LMWH had been ceased and the patient had been discharged. All cases were diagnosed before the 10th postoperative day. Pneumoperitoneum is felt to predispose to deep venous thrombosis. Long operations and reverse Trendelenburg position are further potentiating factors. Thromboprophylaxis for laparoscopy should be the same as for conventional surgery, i.e., tailored to individual risk and continued for a minimum of 7 to 10 days. We also recommend using graduated compression stockings, maintaining a relatively low insufflation pressure, keeping use of the reverse Trendelenberg position to a minimum, and intermittently releasing the pneumoperitoneum in longer procedures.

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.

Resume Objectif La videoparietoscopie a pour objet de reparer certains diastasis des droits et certaines dehiscences parietales de petite taille sans alterer le revetement cutane, surtout pour des raisons esthetiques et specialement chez la femme jeune. Patients et methodes L'abord est sus-pubien ou ombilical selon le siege de la lesion a reparer. Un trocart de 10 mm avec mandrin mousse est place au contact du plan aponevrotique. Apres dissociation initiale du tissu cellulaire, l'insufflation progressive de CO2 decolle le plan cutane de facon extensive en haut et lateralement: un ou deux trocarts de 5 mm permettent la liberation progressive du plan aponevrotique et la mise en evidence des zones pathologiques. Celles-ci sont reparees par des sutures endoparietales classiques ou des points percutanes passes a l'aide d'une aiguille de Reverdin. Quinze patients (14 femmes, un homme) d'âge moyen de 30 ans (19–36) ont ete operes par parietoscopie pour un diastasis des muscles droits (cinq cas), une eventration (trois cas) et une hernie epigastrique ou de la ligne blanche (sept cas). Resultats Une conversion en abord classique a ete necessaire chez un homme porteur d'un diastasis des muscles droits en raison de l'absence de plan de decollement sous-cutane. La reparation a ete possible chez les 14 autres patients. La duree moyenne d'intervention a ete de 1 heure 20 minutes et la duree moyenne d'hospitalisation de 2 jours (1–3). II n'y a eu ni mortalite ni morbidite. Avec un recul moyen de 18 mois (4–40), le resultat esthetique et fonctionnel a ete excellent. Conclusion La videoparietoscopie abdominale permet la reparation de certaines pathologies parietales mineures avec preservation du revetement cutane. Ses indications sont d'ordre esthetique, chez des femmes jeunes ayant une faiblesse ou une dehiscence parietale sous une peau conservee.

Resume Situation Le traitement ≪classique≫ des peritonites generalisees par perforation sigmoidienne est fonde sur le principe d'un traitement chirurgical en deux temps comportant une colostomie temporaire. Cette attitude s'accompagne d'une importante morbidite, notamment parietale. Malades et methodes Dix patients consecutifs, huit femmes, deux hommes, d'âge moyen 54,6 ans, ont ete operes d'urgence par laparoscopie d'une peritonite generalisee par perforation diverticulaire; six avaient eu des poussees infectieuses anterieures; six etaient obeses, cinq hypertendus, quatre diabetiques et deux bronchopathes chroniques. Apres exploration de la cavite abdominale et decouverte d'une peritonite purulente ( n = 8) ou stercorale ( n = 2), un lavage peritoneal abondant a ete realise (15 litres en moyenne), la lesion sigmoidienne infectante a ete encollee a la colle biologique et un drainage peritoneal a ete place au contact et parfois dans les zones declives. Aucune colostomie n'a ete realisee. L'antibiotherapie instituee des le diagnostic pose, a ete poursuivie en moyenne 7 jours. Resultats II n'y a pas eu de mortalite. La morbidite a ete faible: une lymphangite sur catheter et une infection bronchopulmonaire. Aucun patient n'a eu d'abces de paroi ou de collection profonde residuelle. La duree moyenne du sejour hospitalier a ete de 8 jours. Apres un delai de 3 a 4 mois, neuf patients ont eu une resection sigmoidienne dont huit par laparoscopie avec une duree moyenne d'hospitalisation de 6 jours. Une conversion en laparotomie a ete necessaire dans un cas. Conclusions Le traitement laparoscopique des peritonites generalisees dues a une perforation diverticulaire sigmoidienne constitue une alternative a la chirurgie classique, induisant une plus faible morbidite, une reduction nette de la duree d'hospitalisation et permettant surtout d'eviter une colostomie et d'ameliorer la qualite de vie des patients avant la realisation de la colectomie secondaire qui a ete faite huit fois sur neuf par laparoscopie. Cette attitude s'accompagne ainsi d'une diminution significative des couts therapeutiques.

Resume Objectif de l'etude L'objectif de cette etude prospective est d'evaluer l'efficacite de la laparoscopie diagnostique associee a une echolaparoscopie, dans l'appreciation de l'extension du cancer du pancreas en vue de selectionner les patients pouvant beneficier d'une exerese a visee curative. Patients et methodes De juin 1995 a mars 1997, 26 patients consecutifs, 11 hommes et 15 femmes (âge moyen: 62,5 ans) atteints d'un cancer de la tete du pancreas avec ictere, ont ete explores par quatre methodes: echographie transparietale (n = 26) tomodensitometrie (n=26), echoendoscopie (n= 16), laparoscopie diagnostique avec echolaparoscopie (n = 26). L'evaluation de la resecabilite par chaque exploration a ete confrontee avec les constatations chirurgicales et histologiques. Resultats L'echographie transparietale et la tomodensitometrie ont donne des resultats comparables conduisant a une non-resecabilite dans 50 % des cas. L'echoendoscopie realisee chez les 16 patients juges indemnes de metastases d'apres les examens precedents a predit la tumeur resecable dans sept cas seulement. L'association laparoscopie diagnostique et echolaparoscopie a permis de decouvrir des metastases qui avaient echappe a l'imagerie et a juge la tumeur non resecable chez 21 patients sur 26; la sensibilite de cette exploration etait de 100 % pour les metastases hepatiques, les metastases peritoneales et l'envahissement mesentericoportal, de 90 % pour l'envahissement ganglionnaire et de 88 % pour le diagnostic de la tumeur pancreatique. Cinq patients sur 26 ont ete traites par duodenopancreatectomie cephalique. Tous les autres sauf un ont eu un traitement palliatif. Une laparotomie a ete evitee dans 12 cas. Conclusion La laparoscopie diagnostique associee a l'echolaparoscopie, a une efficacite superieure a celle des autres methodes utilisees. Elle doit constituer le premier temps d'une exerese chirurgicale presumee curative (cinq fois sur 26 dans cette serie), mais peut etre egalement suivie d'un geste de derivation. Elle a permis d'eviter la laparotomie 12 fois sur 26.

Laparoscopic ultrasound combines the advantages of diagnostic laparoscopy with peroperative ultrasonography. This new technique allows visualization of deep structures that are not palpable. The technical aspects of this technique and its applications in abdominal surgery are described. The main indications are the search for common bile duct stones during a laparoscopic cholecystectomy and the assessment of the spread of abdominal cancers. The information obtained from laparoscopic ultrasound can influence the therapeutic management.

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.

Summary Objective Our purpose was to evaluate the efficacy and safety of sleeve gastrectomy (SG) at 5 years after surgery. Patients and methods From June 2005 to January 2007, 65 obese patients underwent SG. The percentage of excess weight loss (%EWL) and excess BMI loss (% EBL), obesity-related co-morbidities, and post-SG complications were evaluated at 2 years after SG based on our database, and at 5 years after SG based on a questionnaire sent to the patients by one of the authors (IB) between May 2011 and February 2012. Results A complete data set was obtained for 53 of 65 patients (82%), including 45 patients who had SG as the only surgical treatment, and eight patients who had a second bariatric procedure at a later date because of insufficient weight loss (five gastric bypass (GBP), three SG revision). For these 53 patients, the mean %EWL was 54.4% at 2 years and 53.7% at 5 years, and the mean %EBL was 61% at 2 years and 60% at 5 years. Three patients (5.7%) had post-operative complications (two fistulas (3.8%), one hemorrhage (1.9%)). Three trocar-site hernias (5.7%) were observed between 10 months and 34 months post-SG. Sub-group analysis of the 45 patients who underwent SG alone showed a mean %EWL of 57.1% at 2 years and 50.7% at 5 years; the mean %EBL was 64% at 2 years and 56.8% at 5 years. Of these 45 patients, 13 (28.9%) required medication to treat diabetes (DM) before SG and only five (11.1%) at 5 years after SG (61.5% decrease); 18 (40%) had antihypertensive treatment before SG, and eight (17.8%) at 5 years after SG (55.5% decrease); 12 (26.7%) took lipid-lowering medication before SG, and five (11.1%) at 5 years after SG (58.3% decrease); 24 (53.3%) had sleep apnea (SAS) before SG and six (17.8%) at 5 years after SG (75% decrease). However, while only five patients (11.1%) had GERD requiring PPI therapy before SG, 15 patients required PPI therapy (33.3%) at 5 years after SG (200% increase). Conclusion Five years after performance of SG, weight loss was satisfactory, few complications were observed, the reduction of co-morbidities was significant, but there was an increase in the frequency of GERD.

Objectif Demontrer que la gastrectomie longitudinale (GL) permet d’ameliorer le rapport benefice risque en comparaison au bypass gastrique (BPG) pour la perte de poids, les complications, et la qualite de vie, avec un suivi de 36 mois. Patients et methodes Etude multicentrique comparative randomisee entre GL/BPG chez des patients remplissant les criteres de l’HAS. L’etude teste 2 hypotheses : une hypothese de difference sur la frequence des evenements de morbi-mortalite et une de non-inferiorite sur la reduction de l’exces ponderal superieure a 50 % a 18 mois. Resultats Quarante patients ont ete inclus entre fevrier 2008 et fevrier 2010 (15 BPG vs 25 GL) puis suivis pendant 36 mois revolus. L’âge moyen etait de 43,1 ans, avec 82,5 % de femmes, et un IMC moyen avant intervention de 49 kg/m2 (extremes 43–71). La perte d’un exces poids superieure a 50 % a 18 mois etait de 71,4 % et 62,5 % pour le BPG et la GL respectivement (soit − 8,9 % avec IC95 % [−21,7 % ; 39,5 %]). La borne de l’IC95 % de 39,5 % > 15 % (marge de non-inferiorite) ne nous a pas permis de conclure. Il n’y avait pas difference entre BPG et GL sur le critere composite de morbi-mortalite (p = 0,3446), ni sur l’amelioration globale des comorbidites, ni sur les carences nutritionnelles, ni sur la qualite de vie. Conclusions Ainsi, la GL semble aussi efficace, toleree et sure que le BPG sans atteindre la significativite. Nous attendons les resultats d’une cohorte prospective de 280 patients (incluant 40 patients randomises).

Rationnel La prevalence de l'obesite ne cesse de croitre surtout chez les patients precaires. Notre objectif etait de determiner si la presence d'un gradient de precarite pourrait avoir un impact sur le choix d'une chirurgie bariatrique dans un systeme de soins de sante finance par l'Etat avec une couverture complete des frais medicaux. Patients et Methodes Nous avons inclus de facon prospective 100 patients admis en hopital de jour pour une evaluation preoperatoire avant une chirurgie bariatrique. Comme groupe de reference, nous avons inclus 578 sujets avec un IMC≥35kg/m 2 , dans le meme departement et ayant consulte dans un centre de sante pour leur bilan cardiovasculaire propose par la securite sociale du 01/01 au 31/12/2013. Tous les sujets ont rempli le questionnaire de precarite EPICES (Seuil pour l'absence de precarite Resultats Quatre-vingt quatre candidats a la chirurgie bariatrique avaient des donnees completes : ils etaient plus jeunes avec un âge moyen de 39,2±12,7 annees, ( vs 47,6±13,8, p p =0,030) et une moyenne d'IMC plus elevee 43,3±6,9 ( vs 38,7±3,7kg/m 2 , p vs 51,0±21,9, p vs 82 %, p Conclusions La couverture des besoins materiels, comme les frais medicaux ne suffit pas a la decision d'une chirurgie de l'obesite. D'autres ressources sont certainement necessaires education, soutiens psychologique et social doivent etre systematiquement envisages chez ces patients pour l'acceptation de cette chirurgie.

Background: Sleeve gastrectomy (SG) has been rapidly accepted as a valuable bariatric procedure before its effectiveness on weight loss in the long-term is clearly demonstrated. Re-sleeve gastrectomy (RSG) has been shown to provide promising results for patients with insufficient weight loss after SG. Methods: Seven patients underwent a re-sleeve gastrectomy procedure for insufficient weight loss after a mean 30±10 month follow-up associated with a dilated gastric pouch seen in upper gastro-intestinal contrast study. Results:Before SG, mean initial weight was 151 41 kg, mean Body Mass Index (BMI) was 55.4±12.5 kg/m2, 4 had a BMI more than 60 kg/m2 and 3 had a gastric banding before their SG. At follow-up of 12 months after SG, mean weight was 131 ±31 Kg, mean BMI was 48±9 kg/m2, mean %Excess Weight Loss (EWL) was 30 5%, and mean %Excess BMI Loss (EBL) 23 ±3%. At a follow-up of 12 months after RSG, final mean weight was 92 ±10 Kg, final mean BMI was 34±4 kg/m2, and mean %EBL since the second operation (RSG) was 58±17% (mean %EBL since the first operation (SG) was 6618%), and mean %EWL since the second operation (RSG) was 4217%(mean %EWL since the first operation (SG) was 6618%). The RSG resulted in significant mean %EBL (p

This study reports major gastrointestinal complications in a group of 416 patients following kidney transplantation. Three hundred and ninety-nine patients received a cadaveric kidney while the other 17 received a living related organ. The immunosuppressive regimen changed somewhat during the course of the study but included azathioprine, prednisolone, antilymphocyte globulin, and cyclosporin. Perforations occurred in the colon (n = 6), small bowel (n = 4), duodenum (n = 2), stomach (n = 1), and esophagus (n = 1). There were five cases of acute pancreatitis, four of upper gastrointestinal and two of lower intestinal hemorrhage, two of acute appendicitis, one of acute cholecystitis, one postoperative mesenteric infarction, and two small bowel obstructions. Fifty percent of the complications occurred while patients were being given high-dose immunosuppression to manage either the early postoperative period or episodes of acute rejection. Ten percent of the complications had an iatrogenic cause. Of the 31 patients affected, 10 (30%) died as a direct result of their gastrointestinal complication. This high mortality appears to be related to the effects of the immunosuppression and the associated response to sepsis. Reduction of these complications can be achieved by improved surgical management, preventive measures, prompt diagnosis, and a reduced immunosuppressive protocol.

The incidence of choledocholithiasis (CDL) has been shown to be around 10% when intra-operative cholangiography (IOC) is practised routinely during cholecystectomy [1, 2, 3]. The advent of laparoscopic cholecystectomy has enlivened the debate between those who defend systematic intra-operative opacification of the common bile duct (CBD) [4, 5, 6] and those who advocate a selective approach [7, 8] based on certain predictive factors [9, 10]. IOC remains an invaluable tool for the detection of asymptomatic stones, as well as the prevention and/or detection of possible CBD injuries [11, 12, 13]. Regarding the latter, authors such as Wright [14] have suggested that IOC is not a prerequisite for the safe performance of laparoscopic cholecystectomy and cannot be relied upon to prevent all biliary injuries.

The decision to perform gastroplasty must be made by a multidisciplinary team. This organization ensures compliance with good practice guidelines. Multidisciplinary management after surgery is also essential but patients' adhesion to follow-up is relatively poor.

Introduction Peu d’etudes rapportent les resultats a long terme de la sleeve gastrectomie (SG) apres echec d’anneau gastrique. Notre objectif a ete d’evaluer l’efficacite et la securite de la SG apres echec d’anneau a 7 ans revolus. Methodes De mai 2006 a d ecembre 2007, 36 patients ont eu une SG apres echec d’anneau gastrique. Les pourcentages de perte d’exces de poids (%PEP) et de perte d’exces d’IMC (%PEI), ainsi que les comorbidites liees a l’obesite, et les complications liees a la SG ont ete evaluees 2 ans apres la SG d’apres notre base de donnees, et 7 ans apres la SG d’apres un questionnaire soumis aux patients apres le 7 e anniversaire de la SG, de juin 2013 a decembre 2014. Resultats Un recueil complet des donnees a ete obtenu pour 30 patients (83,3 %) incluant 24 patients qui ont eu une SG comme traitement chirurgical definitif, et 6 patients qui ont eu au moins une autre intervention bariatrique apres la SG, du fait d’une insuffisance de perte de poids (3 bypass gastriques, 2 Re-SG, 1 Re-SG suivie d’un bypass gastrique). Pour ces 30 patients, nous avons constate une PEP moyenne de 58,4 % a 2 ans et 5 1,7 % a 7 ans ; une PEI moyenne de 6 2 % a 2 ans et 5 7,5 % a 7 ans. Quatre patients (13,3 %) ont presente une complication postoperatoire (2 fistules (6,7 %), 1 hemorragie (3,3 %), 1 stenose (3,3 %)). A distance, une seule complication (3,3 %) a type d’eventration sur site de trocart a ete constatee. Parmi ces 30 patients, 7 (23,3 %) avaient un traitement antidiabetique avant la SG et 4 (13,3 %) 7 ans apres ; 9 (30 %) avaient un traitement anti-HTA avant la SG et 6 (20 %) 7 ans apres ; 8 (26,7 %) avaient un traitement hypolipemiant avant la SG, et 5 (16,7 %) 7 ans apres ; 11 (36,7 %) avaient un SAS avant la SG et 5 (16,7 %) 7 ans apres. Par ailleurs, 5 patients (16,7 %) avaient un RGO traite par IPP avant la SG et 9 (30 %) 7 ans apres. Discussion Sept ans revolus apres une SG comme traitement d’un echec d’anneau gastrique, la perte de poids est satisfaisante, une regression des comorbidites a ete constatees et la frequence du RGO augmentee. Declaration d’interet Les auteurs n’ont pas transmis de conflits d’interets.

Objectif Nous avons analyse les habitudes alimentaires et d’activite physique de patientes operees dans notre centre de chirurgie de l’obesite. Patientes et methodes Nous avons adresse par courrier a 713 patientes operees a l’hopital Delafontaine entre avril 2010 et septembre 2013 un auto-questionnaire (NAQAPNNS) simple permettant d’evaluer l’atteinte ou non de chacun des reperes du Programme national nutrition et sante. Ces questionnaires ont ete recueillis par courrier ou directement lors de la reunion de suivi du 20/09/2014. Resultats Au total, 144/713 patientes ont repondu a ce questionnaire. L’âge moyen des patients etait de 46,9 ans (extremes 21–68 ans), avec 86 % de femmes et un IMC moyen avant intervention de 42,2 kg/m2 (extremes 34–65), 125 ont une gastrectomie longitudinale (GL), 9 un By-Pass, 7 un anneau, 2 une reGL. La perte d’IMC moyenne a ete de 12,5 kg/m2 (extreme :–1,1–28,9) pour un suivi moyen de 854 jours (extreme : 143–1538). L’analyse des questionnaires NAQAPNNS a mis en evidence une activite physique a plus de 30 minutes chez 45 % des patients. L’ensemble des patients interroges ont une alimentation plutot equilibree : La consommation de laitage, proteines, produits cerealiers est respectee selon les recommandations. La moitie de cet echantillon respecte les recommandations en fruits et legumes. La consommation de matiere grasse et d’eau est plutot inferieure aux recommandations. Conclusions Ainsi nous constatons que les patientes ayant remplis l’auto-questionnaire declarent avoir des reperes alimentaires et d’activite physique meilleurs que ceux de la population generale.

Situs inversus totalis is a rare defect which can present difficulties in the management in laparoscopic surgery due to the mirror-image anatomy. Herein, we report a patient with situs inversus totalis and super-super-obesity (BMI 76 kg/m2). We performed successful laparoscopic sleeve gastrectomy. Technical details of this operation, with situs inversus totalis, are presented. There were no major difficulties compared to patients with usual anatomy. There are potential diseases associated with situs inversus and obesity; therefore, a careful investigation, including a chest x-ray and cardiac and abdominal ultrasounds should be performed before surgery. Sleeve gastrectomy is an adequate procedure in super-super-obese patients with situs inversus totalis.

Background The application of laparoscopy for malignancy has been halted in many centres because of a growing number of reports of metastases arising in port sites. The smoke created by coagulation during laparoscopic surgery appears to contain particles visible to the naked eye. This study tested the hypothesis that whole cells can be carried as an aerosol in the pneumoperitoneum during laparoscopy. Methods Nine patients undergoing laparoscopic surgery for benign and metastatic disease were studied. Throughout the procedure the gas of the pneumoperitoneum was allowed to escape through a filter. The filters and tubing were washed, and washing solution was centrifuged and stained immunohistochemically to identify the cells. Three of the filters were also examined with an electron microscope. Results Six of the nine samples contained cells. Clumps of whole cells were identified as mesothelial in origin; the electron micrographs showed many other cells stuck to the filter, which appeared to be blood and mesothelial cells but were not analysed further. Conclusion The presence of whole identifiable cells carried in the pneumoperitoneum raises concerns for operating staff and could be a mechanism for tumour implantation. No malignant cells were found, but ethical considerations prevented intentional coagulation of malignant tissue.

Objectif Le bypass gastrique (BP) souvent realise chez des super super obeses presente des taux de complications eleves. La technique de gastrectomie longitudinale (« sleeve gastrectomie » (SG)) plus recente donne des taux de complications plus faibles mais est estimee moins performante pour la perte de poids. Notre objectif etait d’evaluer la perte de poids et les complications per operatoires chez 30 patients presentant un Index de Masse Corporelle (IMC) > 60 kgKg/m2 operes d’une gastrectomie longitudinale. Patients et methodes Cette etude prospective inclut 23 femmes, 7 hommes, d’âge moyen 35 ans (18–59), avec un IMC preoperatoire moyen de 66 kgKg/m2 (60–85), et un poids moyen de 168 kg (140–258). Les donnees evaluees sont le temps operatoire, les complications, le pourcentage de perte d’exces de poids ainsi que la necessite d’une seconde intervention. Un patient presentait un situs inversus complet et 4 patients avaient deja eu un anneau gastrique Resultats Le temps moyen operatoire etait de 120 minutes (80–220), avec un sejour hospitalier moyen de 7,5 jours (4–28 j) et une mortalite postoperatoire nulle. Les complications post operatoires immediates etaient deux hematomes sous-phreniques, une fistule gastrique et une embolie pulmonaire. Parmi les 30 patients, 23 avaient un suivi suffisant de 18 mois, et 17 presentaient des resultats juges satisfaisants. Pour les 6 autres patients avec une perte de poids insuffisante, 3 ont eu une deuxieme SG, 2 un BP gastrique et un patient a refuse une seconde intervention. Trois ans apres la SG initiale, la perte moyenne d’exces de poids etait de 51 % (21–82 %) et la perte moyenne d’IMC de 20 kgKg/m2 (10–39 kg/m2) Conclusion La sleeve gastrectomie est une operation efficace chez les super super obeses associee a tres peu de complications et a une mortalite post operatoire nulle. Dans le cas d’une perte insuffisante de poids une deuxieme operation peut etre proposee.

The role of laparoscopic resection in the management of colorectal cancer is still unclear. It has been shown that laparoscopic colectomies can be accomplished with acceptable morbidity. Major concerns are port-site recurrences and neoplastic dissemination. The aims of this study were to compare perioperative results and long-term outcomes in a prospective, nonrandomized study of patients treated by laparoscopic versus open colorectal resection for cancer. In particular, the effects of an initial laparoscopic approach on survival and recurrence were examined. One hundred fifty-seven patients with colorectal carcinoma were included in the prospective trial: 74 underwent laparoscopic resection and 83 underwent conventional open surgery. The two groups were comparable in terms of characteristics, demographic data, stage of disease, and use of adjuvant or palliative chemoradiotherapy. All patients were observed at 1.3- and 6-month intervals. The median duration of follow-up was 60 months (range, 10-125 months). The mean operating time was significantly longer in the laparoscopic group. Six conversions (8.1%) were necessary. The passage of flatus and the restarting of oral intake (P = 0.0001) occurred earlier in the laparoscopic surgery group than in the open conventional surgery group. The mean postoperative stay was significantly shorter in the former group (P = 0.005), as was the length of the scar (P = 0.001). There were no deaths in either group. The overall morbidity was significantly lower (13% versus 33.7%; P = 0.001) in patients treated laparoscopically. No significant differences were observed between the groups in the length of specimens, the size of the tumor, or the number of nodes removed. Late complications were more frequent after open resection (12% versus 5.4%; P = 0.01). Two port-site metastases (2.6%) were seen in stage III and IV locally advanced carcinoma. There was no significant difference in recurrent disease between the groups (24.3% versus 25%) during the 60-month follow-up. Stage-for-stage comparisons showed that disease recurrence rates and crude death rates were comparable.

This study was a prospective evaluation of the quality of life of 50 patients after laparoscopic total fundoplication surgery for gastroesophageal reflux disease. The quality of life of 50 consecutive patients who underwent laparoscopic total fundoplication was evaluated using the Gastrointestinal Quality of Life Index questionnaire, which included 36 items in five different areas: symptoms, physical well-being, psychologic well-being, social relationships, and effects of medical treatment. Twenty-seven men and 23 women with a mean age of 52.6 +/- 16 years (range, 31-68 years) with gastroesophageal reflux disease were treated by laparoscopic total fundoplication (Nissen-Rosetti) and were included in the study. The follow-up was at least 2 years after surgery. The quality of life was evaluated before the surgery and 1 month, 3 months, 6 months, 1 year, and 2 years after surgery with follow-up in 100% of the cases. A control group of 50 healthy volunteers representing an identical population to that of the patients operated on (with respect to age, sex, body mass index, profession, and smoking) anonymously completed the same questionnaire. The preoperative and postoperative Gastrointestinal Quality of Life Index questionnaire scores of patients who had laparoscopic total fundoplication were compared with the Gastrointestinal Quality of Life Index questionnaire scores of the control group. Before surgery, the Gastrointestinal Quality of Life Index questionnaire score (86.7 +/- 8.5) was much inferior to that of the control group (123.8 +/- 13.6) (P < 0.001). This score significantly improved 3 months after surgery and was comparable (not significant) to that of the healthy control population 3 months, 6 months, 1 year, and 2 years after surgery (119.3 +/- 7.8). Improvements were reported mainly with respect to gastrointestinal symptoms and physical well-being. Social relationships were not modified. The quality of life of patients after laparoscopic surgery for gastroesophageal reflux disease improved and was close to the level expected in a healthy individual.

Six a 12 mois de conseils dietetiques sont necessaires selon les recommandations de l’HAS pour les candidats a la chirurgie de l’obesite. Au cours d’une etude observationnelle, nous avons evalue les habitudes alimentaires et d’activite physique chez 100 patients candidats a la chirurgie bariatrique par un auto-questionnaire (NAQA). L’âge moyen des patients etait de 40 ans (extremes 17–70 ans), avec 87 % de femmes et un IMC moyen de 42,6 kg/m2 (extremes 31–69), 60 % etaient consideres comme precaires avec un score EPICES ≥ 30,17. Au total, 81 dossiers ont ete analyses (72 femmes et 9 hommes). L’analyse des questionnaires NAQA a mis en evidence, chez tous les patients sans exception, des erreurs alimentaires importantes. L’estimation calorique moyenne etait de 2146 kal/j et 1758 kcal/j pour les hommes et les femmes, 27,8 % des patients sautaient > 2 repas/semaine, 43,1 % ne prenaient pas de petit dejeuner, 38,9 % faisaient de la friture > 2/semaine, 32 % consommaient du beurre > 2 fois/jour, 59,7 % et 51,4 % ne consommaient pas de legumes ou de fruits tous les jours. 23,3 % buvaient > ½ litre de boisson sucree/j. Par ailleurs les patients precaires consommaient plus de pain, de beurre et avaient moins d’activite physique de maniere significative. Ainsi nous avons constate de graves erreurs dietetiques chez tous ces patients obeses, que la chirurgie ne pourra pas corriger. L’education alimentaire de 6 a 12 mois, recommandee ne doit pas etre une etape facultative. Cette etude pourrait orienter les conseils a donner.

Il existe une augmentation de la prevalence de l’obesite dans les populations les plus precaires en France. Notre objectif a ete d’apprecier le niveau de precarite des candidats a une chirurgie bariatrique et de le comparer a celui d’une population obese qui consulte dans un centre d’examens de sante voisin de l’etablissement. Nous avons mene une etude observationnelle transversale chez 100 patients candidats a la chirurgie bariatrique. Nous avons mis en relation les donnees cliniques et les reponses a deux auto-questionnaires : le score de qualite de vie BAROS et celui de precarite EPICES (Normale Pour les 100 patients hospitaliers, l’âge moyen etait de 40 ans (extremes 17–70 ans), avec 87 % de femmes et un IMC moyen de 42,6 kg/m 2 (extremes 31–69). Le score EPICES moyen etait de 38,6 donc precaire. Le score BAROS montre que 76 % des candidats avaient une mauvaise la qualite de vie. Le groupe de reference de 578 sujets avait un score EPICES moyen de 51 (superieur a notre population hospitaliere). Nous n’avons pas mis en evidence, de relation entre l’IMC et le score de precarite, chez ces deux populations. Les candidats a une chirurgie bariatrique hospitalier de Saint-Denis sont beaucoup moins precaires qu’une la population obese voisine. La situation sociale des grands precaires pourrait leur donner moins acces a ce traitement efficace.

Objectif Il existe une augmentation de la prevalence de l’obesite dans les populations les plus precaires en France. Notre objectif a ete d’apprecier le niveau de precarite des candidats a une chirurgie bariatrique pris en charge dans notre etablissement et de le comparer a celui d’une population obese qui consulte dans un centre de sante voisin de l’etablissement. Methodes Nous avons mene une etude observationnelle transversale chez 100 patients candidats a la chirurgie bariatrique vus consecutivement en hospitalisation de jour au Centre Hospitalier de Saint-Denis. Nous avons mis en relation les donnees cliniques et les reponses a deux auto questionnaires : le score de qualite de vie BAROS et celui de precarite EPICES (seuil de precarite fixe par convention a 30,17 %). Nous avons compare ces donnees a un groupe de reference de 578 sujets avec un IMC ≥ 35 extraits d’un groupe plus important de 7 812 sujets vus en 2012 au Centre de Sante de l’Assurance Maladie de Bobigny. Resultats Pour les 100 patients hospitaliers, l’âge moyen etait de 40 ans (extremes 17–70 ans), avec 87 % de femmes et un IMC moyen de 42,6 kg/m 2 (extremes 31–69). Le score EPICES moyen etait de 38,6 % donc precaire. Le score BAROS a considere comme mauvaise la qualite de vie des candidats a une chirurgie bariatrique dans 76 % des cas. Le groupe de reference de 578 sujets avec un IMC ≥35 vus en 2012 au Centre de Sante a Bobigny avait un score EPICES moyen de 51 (superieur a notre population hospitaliere). Il n’y avait pas, pour ces deux populations, de relation entre l’IMC et le score de precarite. Conclusion Les candidats a une chirurgie bariatrique pris en charge au Centre Hospitalier de Saint-Denis ont une mauvaise qualite de vie et sont precaires, mais beaucoup moins precaires que la population obese qui consulte dans le centre de sante voisin de l’etablissement.

Le Dumping syndrome est une complication frequente du By Pass (BP). Il peut etre precoce (malaise digestif) ou tardif (hypoglycemie). Le diagnostic est fait sur une conviction clinique et la mise en evidence d’hypoglycemies post prandiales tardives. Le traitement repose habituellement sur des mesures dietetiques ; l’acarbose (ou d’autres medicaments ont ete proposes dans les cas refractaires). Sa physiopatholologie n’est pas totalement elucidee. Recemment, on a mis en evidence une augmentation de la captation du 18 FDG en tomographie par emission de positons (TEP) multipliee par deux par l’intestin grele atteignant des taux proches de ceux du cerveau chez les rats apres BP [1] . Nous avons voulu confirmer cette hypothese chez 2 patientes porteuses de BP souffrant de Dumping syndrome avec hypoglycemies documentees. Les deux patientes âgees de 38 et 55 ans avaient eu respectivement un BP en 2009 (117 = >66) et 2007 (139 = > 90 kgs). La seconde patiente souffrait de diabete equilibre par metformine. Les patientes n’ont pas eu de malaise pendant la realisation des examens de TEP-FDG. Ces derniers n’ont pas montre d’hyperfixation grelique. Ainsi notre hypothese d’une augmentation de la consommation de glucose par l’intestin grele n’a pas ete demontree dans ces deux cas. Soit les mecanismes de reprogrammation chez le rat ne sont pas identiques a ceux de l’homme. Soit la periode d’observation de cette modification s’estompe avec le temps. En tout cas cela n’est pas en relation avec le Dumping syndrome.

Objective: despite recent advances in medical imaging, pre-operative evaluation of liver tumors, whether benign or malignant, is often lacking in accuracy and precision. With the development of surgical laparoscopy, the benefits of diagnostic laparoscopy have been combined with those of operative ultrasound. This article aims to describe the technique of laparoscopic ultrasound of the liver, and to define its applications and the role of its association with diagnostic laparoscopy in the localization and assessment for resectability of liver tumors. Methods: after an initial visual inspection with the laparoscope, laparoscopic ultrasound is utilized to further examine the liver. This relies largely on recognition of branches of the portal vein and tributaries of the hepatic veins. During this procedure, the hepatic parenchyma is also examined. Minimal displacement of the transducer, using clockwise and anti-clockwise rotatory movements, allows a full exploration of the liver. Results: the combination of visual with sonographic laparoscopy allows accurate localization of benign and malignant hepatic tumors, as well as ultrasound-guided biopsies of these. Laparoscopic ultrasound can detect small lesions previously unseen by pre-operative imaging techniques. The relationship of tumors to adjacent blood vessels can be defined. Portal vein thrombosis can be diagnosed. Conclusion: curability and liver tumor resectability can be determined and the appropriate surgical treatment thus planned.

A case of laparoscopic autopsy for unexplained inpatient death is reported. The procedure is minimally invasive, easy to perform, accurate, and not disfiguring, rendering it easy to accept among mourning families.

Pancreatic resection with curative intent is possible in a select minority of patients with carcinomas of the pancreatic head. Diagnostic laparoscopy supported by laparoscopic ultrasonography combines the proven benefits of staging laparoscopy with high-resolution intraoperative ultrasound, thus allowing the surgeon to perform a detailed assessment of the pancreatic cancer.In a prospective study of 26 patients with obstructive jaundice from a carcinoma of the head of the pancreas, the curative resectability of tumors was assessed by ultrasound (26 cases), computerized tomography (26 cases), endoscopic ultrasound (16 cases), and a combination of diagnostic laparoscopy and laparoscopic ultrasound (26 cases).The findings of ultrasound and computerized tomography were comparable: 50% of patients were excluded from curative resection. Endoscopic ultrasound provided precise information on the primary tumors. The accuracy of the combined diagnostic laparoscopy and laparoscopic ultrasound, when compared with ultrasound, computerized tomography, and endoscopic ultrasound, was better with respect to minute peritoneal or hepatic metastasis: 80.7% (or a further 30.7%) of patients did not qualify for curative resection.Diagnostic laparoscopy supported by laparoscopic ultrasonography enables detection of previously unsuspected metastases; thus, needless laparotomy can be avoided. It should therefore be considered the first step in any potentially curative surgical procedure.

Background Laparoscopic sleeve gastrectomy (LSG) is one of the common bariatric procedures for the treatment of morbid obesity. One of the most drastic complications of this procedure is leak. Objective The aim of the study was to discuss the possible technical factors that might contribute to the occurrence of postoperative leak and how to avoid it through analyzing our series. Materials and methods Analysis of the influence of technical adaptations on the outcome of LSG was performed in a nested case-control group of patients. The main modification adapted was performing invaginating sutures over the staple line. The primary outcome was the occurrence of leak. The secondary outcomes were bleeding, operative time, prolonged hospital stay, back pain, and mortality. Results The group who had invaginating sutures (group 2) had a significantly lower frequency of leak (0%) than those without invaginating sutures (7.3%; group 1) (PF = 0.016). There was no significant difference in the occurrence of postoperative bleeding or mortality between the groups (PF = 0.162 and 0.250, respectively). The frequencies of a hospital stay longer than 48 h and back pain were significantly higher in group 1 (PF = 0.004, PF There were no significant differences between groups in the preoperative BMI (Student's t = 0−0.763, P = 0.45) or the age (Student's t = −0.5, P = 0.61). The operative time was longer in group 1 (Student's t = 3.56, P Conclusion From our experience, leak after LSG could be minimized by invaginating sutures of the staple line and by adapting the ergonomic trocar positioning described herein.