Search

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) became the most frequently performed bariatric procedure worldwide, gaining rapidly popularity thanks to its technical simplicity and the relatively good results. The aim of this Belgian-French study was to evaluate postoperative complications, weight loss, and resolution of obesity-related comorbidities after LSG, and identify predictive factors of weight loss failure. PATIENTS AND METHODS: A prospective multicenter study was conducted on all LSG performed during 2014 in 7 centers. Their demographic, preoperative, and postoperative data were prospectively collected and analyzed statistically. RESULTS: Overall 529 patients underwent LSG, with a mean preoperative weight and body mass index (BMI) of 118.9 ± 19.9 kg and 42.9 ± 5.5 kg/m2, respectively. Postoperative mortality was null and early postoperative morbidity was 6%, including 2.5% of gastric leakage. BMI significantly decreased to 31.1 kg/m2 and 30.0 kg/m2 at 1 and 3 years, respectively (p < .001). The mean %EWL was 77.2 and 74.6% at 1 and 3 years. A significant reduction in dyslipidemia (28.0-16.8%), obstructive sleep apnea (OSAS) (34.6-23.3%) and arterial hypertension (HTN) (30.4-20.2%) was observed after 3 years, but it does not concern diabetes and gastroesophageal reflux disease (GERD). At multivariate analysis, age > 50 years old, BMI >50 kg/m2 and previous laparoscopic adjustable gastric banding (LAGB) remained independent predictors of weight loss failure. CONCLUSIONS: LSG for morbid obesity is safe and effective. Satisfactory outcome after 3 years can be achieved regarding %EWL and some comorbidities such as dyslipidemia, OSAS, and HTN, but not diabetes and GERD. Age > 50 years old, BMI > 50 kg/m2 and previous LAGB were independent predictors of weight loss failure.

Summary Malpractice claims are a regularly increasing concern in gastrointestinal surgery. The goal of this study was to compare the current status of claims in two different French-speaking communities by a retrospective descriptive study of surgeons’ experiences, from the beginning of their practice up until December 31 2014. Data included the number, the reasons, and the results of medicolegal claims and their jurisdictions. Forty-three surgeons participated in this study. Two hundred medicolegal claims were analyzed. The mean number was 5.8 per surgeon. Bariatric surgery, colorectal surgery and parietal surgery were the most exposed. Forty-six (23%) faults were noted, while no fault was pronounced in 139 (69.5%) cases. The main reasons for lodging complaints were nosocomial infections, anastomotic leaks, poor postoperative care, hollow organ perforation, peripheral neurologic complication, and insufficient preoperative information. Forty-four percent of the complaints were analyzed by the conciliation and compensation commissions and 43.5% by the High Court. In the French-speaking group, there were 13 complaints, two of which gave rise to compensation. French surgeons are highly exposed to complaints: in French law, clumsiness or technical maladdress is considered as a fault. The patient should be informed preoperatively of all possible severe risks of a medical procedure. In Belgium, complications are exceptional and are considered random therapeutic events. Adhering to the recommendations emanating from the French High Authority of Health and Learned Societies as well as accreditation issued by the same High Authority should allow to decrease the number of undesirable events related to care and malpractice.

Resume La sinistralite en chirurgie viscerale constitue un sujet preoccupant et sa frequence augmente regulierement. Le but de cette etude est de realiser au sein d’un groupe de 50 chirurgiens un etat des lieux avec comparaison de 2 groupes francophones. Il s’agit d’une etude retrospective descriptive realisee depuis l’installation des 50 chirurgiens jusqu’au 31 decembre 2014. Les donnees principales repertoriees etaient le nombre, les motifs, les resultats des plaintes et les juridictions concernees. Quarante-trois chirurgiens ont participe a cette etude. Dans le groupe « francais », 200 plaintes ont ete analysees. Le nombre moyen de plainte etait de 5,8 par chirurgien. Les interventions chirurgicales les plus exposees ont ete la chirurgie bariatrique, la chirurgie colo-rectale et la chirurgie parietale. Aucune faute n’a ete retrouvee dans 69,5 % des cas. Quarante-six fautes ont ete notees et representent 23 % des plaintes). Les motifs principaux des plaintes etaient : infection nosocomiale, fistule anastomotique mauvaise prise en charge postoperatoire, perforation d’un organe creux, complication neurologique peripherique, information preoperatoire insuffisante. Quarante-quatre pour cent des plaintes ont ete analysees par la commission de conciliation et d’indemnisation (CCI) et 43,5 % par le tribunal de grande instance (TGI). Dans le groupe « francophone », il a ete retrouve 13 plaintes dont seules 2 ont fait l’objet d’une indemnisation. Les chirurgiens francais sont tres exposes aux plaintes : pour le droit francais, une maladresse est consideree comme une faute et le patient doit etre informe en preoperatoire de tout risque grave d’un acte medical. En Belgique, les complications exceptionnelles sont des aleas therapeutiques. Le respect des recommandations donnees par la haute autorite de sante (HAS) et les societes savante et l’accreditation par l’HAS des chirurgiens francais doivent permettre de diminuer les evenements indesirables lies aux soins et la sinistralite.

Background Sleeve gastrectomy (SG) is the most frequently performed bariatric procedure in the world. Our purpose was to evaluate the percentage of excess weight loss (%EWL), resolution of obesity-related comorbidities after SG, and identify predictive factors of weight loss failure. Methods A prospective cohort study of adults who underwent SG during 2014 in 7 Belgian-French centers. Their demographic, preoperative, and postoperative data were prospectively collected and analyzed statistically. Results Overall, 529 patients underwent SG, with a mean preoperative weight and body mass index (BMI) of 118.9 ± 19.9 kg and 42.9 ± 5.5 kg/m2, respectively. Body mass index significantly decreased to 32.2 kg/m2 at 5 years ( P < .001). The mean %EWL was 63.6% at 5 years. A significant reduction in dyslipidemia (28.0%-18.2%), obstructive sleep apnea (OSAS) (34.6%-25.1%), and arterial hypertension (HTN) (30.4%-21.5%) was observed after 5 years, but not for diabetes and gastroesophageal reflux disease (GERD). At multivariate analysis, age >50 years old, BMI >50 kg/m2, and previous laparoscopic adjustable gastric banding (LAGB) remained independent predictors of weight loss failure. Conclusions Five years after SG, weight loss was satisfactory; the reduction of comorbidities was significant for dyslipidemia, OSAS, and HTN, but not diabetes and GERD. Age >50 years old, BMI >50 kg/m2, and previous LAGB were independent predictors of weight loss failure.

Background Outpatient surgery is a major public health policy issue. It is controversial for total thyroidectomy, which raises the question of hemithyroidectomy. The present study assessed our experience in outpatient hemithyroidectomy. Objectives To evaluate the rates of postoperative hematoma and unscheduled hospital admission. Material and methods A multicenter retrospective analysis was conducted in two hospital centers between January 2009 and December 2013. Exclusion criteria for outpatient hemithyroidectomy comprised: ASA score >2, anticoagulant therapy, risk of completion procedure, and associated procedure requiring >12 hours’ surveillance. Data were collated for age, gender, weight, postoperative complications, and unscheduled hospital admission. Results During the study period, 294 hemithyroidectomies were performed, 130 of which on an outpatient basis (44%). There were no medical contraindications to outpatient surgery in 64% of patients operated on under conventional admission. In the outpatient group, mean age was 44 years. Eight completion thyroidectomies were performed in the outpatient group, and only two patients required admission for surveillance, with no revision surgeries. All patients were satisfied or very satisfied with outpatient management. Conclusion In our experience, outpatient hemithyroidectomy was safe and reliable.

Resume Buts La prise en charge en ambulatoire constitue un enjeu majeur de la politique de sante publique. La realisation des thyroidectomies totales en ambulatoire reste discutee, mais qu’en est-il pour les hemi-thyroidectomies ? Le but de notre etude est d’evaluer notre experience concernant la prise en charge ambulatoire des hemi-thyroidectomies. Materiels et methodes Il s’agit d’une etude analytique retrospective multicentrique, realisee sur deux centres hospitaliers entre le premier janvier 2009 et le 31 decembre 2013. La prise en charge ambulatoire des hemi-thyroidectomies n’etait pas permise si : le score ASA etait superieur a 2, le patient etait sous anticoagulant, le risque de totalisation etait present et en cas d’association d’un autre acte chirurgical necessitant une surveillance > 12 h. Les criteres suivants ont ete recenses : âge, poids, sexe, complications postoperatoires, taux d’admission et d’hospitalisation non programmes. Objectifs Analyser le taux de reprise pour hematome ainsi que le taux d’admission et d’hospitalisation non programmes. Resultats Sur 294 hemi-thyroidectomies realisees durant cette periode, 130 l’ont ete en ambulatoire (soit environ 44 %). Nous n’avons pas retrouve d’obstacle medical a la prise en charge ambulatoire chez environ 64 % des patients pris en charge en hospitalisation conventionnelle. L’âge moyen en ambulatoire etait de 44 ans. Huit totalisations ont ete realisees en ambulatoire. Seuls 2 patients initialement prevus en ambulatoire ont finalement passe une nuit d’hospitalisation pour surveillance, sans aucune reprise. Tous les patients etaient satisfaits voire tres satisfaits de la prise en charge ambulatoire. Conclusion Dans notre pratique, la realisation d’une hemi-thyroidectomies en ambulatoire est une procedure fiable et sure.

Background: Laparoscopic total gastrectomy with extended lymphadenectomy is a technically demanding surgical procedure with steep learning curve that has limited its widespread use. The aim of this study was to evaluate the feasibility of the robotic approach in total gastrectomy for cancer. We present our experience of 17 consecutive patients who underwent robotic total gastrectomy with intracorporal sutured Roux-en-Y esophagojejunostomy and jejuno jejunostomy between 2014 and 2017. Methods: Data were collected, and patients' demographics and outcomes were examined retrospectively. Results: Seventeen patients with a median age of 68 years (range 32-81) were identified (10 males, 7 females). Mean operative time was 198 minutes (range 108-277) including mean anastomosis time of 25 minutes (range 18-35). There was no conversion to open surgery or requirement for perioperative blood transfusion. Median length of hospital stay was 9 days (range 2-30). Two patients developed postoperative complications including one anastomotic leakage treated conservatively and one internal hernia requiring surgical revision. There was no 90-day mortality or readmission. Conclusion: Robot-assisted total gastrectomy is feasible and reproducible. It overcomes several laparoscopic technical difficulties especially regarding anastomosis. It has the potential to become an alternative to open gastrectomy for gastric cancer. Nevertheless, further follow-up and randomized clinical trials are needed to evaluate mid-term and long-term outcomes of this approach.

Introduction: Parathyroid autotransplantation is an easy procedure with a low complication rate. We adopted the transplantation into the sternocleidomastoid muscle, which allows an easier and time-saving surgical procedure using the same surgical incision. Methods: In this study, we retrospectively reviewed the records of 396 consecutive patients, who underwent total thyroidectomy for benign thyroid disease. In all cases in which a parathyroid was damaged or inadvertently removed, the gland was transplanted; before the autotransplantation, the parathyroid tissue was put in a cell culture nutrient solution for 5 min, afterward fragmented, and then was transplanted in the sternocleidomastoid muscle. To demonstrate a beneficial effect of the cell nutrient solution step, we compared data of transplanted patients with a control group of cases (n = 190) undergoing a standard immediate autotransplantation. Results: We divided patients in two main groups: group A (n = 160) including subjects that underwent one or more parathyroid gland autotransplantation using the cell nutrient solution, and group B (n = 236) concerning those who were not transplanted. Among patients, 62 hypocalcemias occurred, 40 in the group A and 22 in the group B (P

The gastro-intestinal neuroectodermal tumor (GNET) is a rare sarcoma of the digestive tract, which was recently recognised. The knowledge of the morphological, immunohistochemical and molecular diagnostic criteria is necessary to not mistake it for the metastasis of a melanoma or for another sarcoma of the digestive tract as the gastro-intestinal clear cells sarcoma or the malignant peripheral nervous system tumor (MPNST). We report the case of a 41-year-old patient with a GNET of the small intestine with hepatic metastasis. The histological examination showed a diffuse proliferation of epithelioid cells, which only express PS100. The presence EWSR1-ATF1 gene fusions with any melanocytic differentiation leads to the diagnosis of GNET.

Objective Incidental thyroid cancers (ITCs) are often microcarcinomas; among them, the most frequent histotype is the papillary one. The purpose of this study was to evaluate the rate of papillary thyroid cancer (PTC) in patients thyroidectomized for benign multinodular goiter. Subject and methods We retrospectively evaluated the histological incidence of PTC in 207 consecutive patients who, in a 1-year period, underwent thyroidectomy for benign multinodular goiter. All patients came from an iodine-deficient area (Orleans, France) with three nuclear power stations located in the neighboring areas of the county town. Results Overall, 25 thyroids (12.1%) harbored 37 PTC, of which 31 were microcarcinomas. In these 25 PTC patients, mean age was 55 ± 10 years (range 30-75), female:male ratio 20:5 (4:1). In 10 patients (40% of 25 and 4.8% of 207), PTCs were bilateral, and in 7 (2 with microPTCs) the thyroid capsule was infiltrated. These 7 patients underwent central and lateral cervical lymph node dissections, which revealed lymph node metastases in one and two cases, respectively. Radioiodine treatment was performed in 7 cases. Neither mortality nor transient and permanent nerve injuries were observed. Four (16%) transient hypocalcaemias occurred as early complications. At last follow-up visit (mean length of follow-up 17.2 ± 3.4 months), all patients were doing well and free of any clinical local recurrence or distant metastases. Conclusion With a 12% risk that multinodular goiter harbors preoperatively unsuspected PTCs, which can have already infiltrated the capsule and that can be accompanied by PTC foci contralaterally, an adequate surgical approach has to be considered.

Laparoscopic major liver resections are regarded as demanding operations whose convenience is still under evaluation. The aim of the present study was to report our early experience and to describe surgical technique of laparoscopic major liver resections. Study group consisted of 6 female patients with benign disease and a mean age of 40.5 years, who underwent right hepatectomy in 4 cases and left hepatectomy in 2 cases. No mortality was observed. Morbidity consists in 1 biliary fistula that requires rehospitalization and a new laparoscopic operation. The mean operative time was of 201.7 minutes, with a mean hospital stay of 5.5 days. The authors conclude that laparoscopic major liver resections could be performed, at least for benign disease and by surgeons experienced in laparoscopy, with good results. Nevertheless, further studies are required before to draw definitive conclusions, especially for neoplastic patients who represent the most relevant group.

The gastro-intestinal neuroectodermal tumor (GNET) is a rare sarcoma of the digestive tract, which was recently recognised. The knowledge of the morphological, immunohistochemical and molecular diagnostic criteria is necessary to not mistake it for the metastasis of a melanoma or for another sarcoma of the digestive tract as the gastro-intestinal clear cells sarcoma or the malignant peripheral nervous system tumor (MPNST). We report the case of a 41-year-old patient with a GNET of the small intestine with hepatic metastasis. The histological examination showed a diffuse proliferation of epithelioid cells, which only express PS100. The presence EWSR1-ATF1 gene fusions with any melanocytic differentiation leads to the diagnosis of GNET.

A 51‐year‐old male was admitted for a mild abdominal pain localized in the upper right side quadrant, without any positive Murphy's sign, associated to a drug‐resistant increasing itching, started 4 days before. Laboratory values were normal except for a light cholestasis and cytolysis (conjugated bilirubin 1.4 mg/dL [normal range 0–0.3], γGT 98U/L [0–50], AST 115U/L [0–42], ALT 137U/L [0–50]); hepatitis markers were negative. Abdominal ultrasound showed an acalculous cholecystitis associated to a choledochal dilatation without a clear evidence of obstruction. Early diagnosis was realized by a contrast‐enhanced computed tomography (CT) that highlighted a suspect solid mass of the distal choledochal duct (Fig. ​(Fig.1)1) with an upper dilatation (12 mm) and multiple celiac adenopathies. No distant metastases were found. The biliary tree obstruction features were deeply investigated by means of magnetic resonance cholangiopancreatography and endoscopic ultrasound scan (Figs. ​(Figs.22 and ​and3).3). The patient underwent open cephalic pancreaticoduodenectomy according to Whipple's procedure, which resulted in a complete tumor removal. Postoperative course was uneventful and the patient was discharged on the 12th postoperative day. Histological examination showed a moderately differentiated (3 cm in its greatest diameter) cholangiocarcinoma (pT2N0M0, stage II), with a well differentiated intraluminal portion, no lymph nodes were involved by metastases. Adjuvant chemotherapy (3 high‐dose cycles of 5‐fluorouracil and cisplatin) and radiotherapy (50 Gy) were performed. After an 18‐month follow‐up, the patient was doing well and free from any local recurrence or distant metastases. Figure 1 Contrast‐enhanced CT with bidimensional reconstruction showed a suspect intraluminal obstruction with the upper dilatation (12 mm) of the choledochal duct (arrow). Figure 2 Magnetic resonance cholangiopancreatography indicated a round polypoid mass in the distal biliary tract and confirmed that choledochal duct was ectasic (arrow). Figure 3 Endoscopic ultrasound scan: hypoechoic findings of the distal biliary tract tumor (arrow). Cholangiocarcinoma is a malignancy arising from the epithelium of the bile ducts, from the hepatic parenchyma to the ampulla of Vater. Extrahepatic cholangiocarcinoma is less common than the perihilar variety and originates in the distal part of the biliary tree 1. Accurate preoperative localization by integrated imaging techniques is helpful for surgical management 1. Jaundice occurs, as first symptom, in more than 90% of all biliary tumors, and generally, it is followed by itching due to biliary salts accumulation and high stimulation of nervous fibers of dermal–epidermal junction 2. In the present case, we hypothesize itching related to a hypersensitivity of the skin nervous fibers. In conclusion, a prolonged itching, resistant to drugs and without jaundice, can be also considered as an early symptom of cholangiocarcinoma.

We report our prospective experience of short-stay hospitalisation for benign thyroid surgery. Post-operative outcome, complication rate and duration of hospitalisation were evaluated for 200 similar patients with bilateral multi-nodular goitres treated surgically by total thyroidectomy. All subjects gave written informed consent. A short-stay regimen, with discharge within 24 h of admission, was possible in 92.5 %. Fourteen (7 %) were discharged on the second post-operative day and one on the fourth post-operative day. Causes of the 15 delayed discharges beyond 24 h were 11 hypocalcaemia (5.5 %), 3 heamatoma (1.5 %) and 1 dysphonia (0.5 %). All compressive haematomata were treated by urgent reoperation. No mortality occurred. None required tracheostomies. Transient complications were diagnosed in 36 cases: 25 with hypocalcaemia and 11 with recurrent laryngeal nerve injuries. Permanent complications were observed in three patients: two with hypoparathyroidism and one with nerve damage. All patients were carefully counselled about potential thyroid surgery complications and a 24-h emergency-contact number was provided. Short-stay hospitalisation represents safe and cost-saving surgical management for benign thyroid surgery.

Hypothesis Occurrence of adverse effects and advantages of the LigaSure diathermy system (or LigaSure vessel sealing system) in total thyroidectomy have not been tested in prospective randomized studies comparing its use with that of the time-saving clamp-and-tie technique to ligate and divide thyroid vessels. The effectiveness of LigaSure in achieving vessel division and hemostasis remains dependent on vessel diameter, and the risk of damage to adjacent structures cannot be completely excluded. We tested the hypothesis that use of LigaSure compared with the clamp-and-tie technique can significantly and conveniently reduce operative time without increasing postoperative complications in patients undergoing total thyroidectomy for benign multinodular goiter. Design Prospective randomized study. Setting Regional hospital. Patients Two hundred consecutive patients with benign multinodular goiter undergoing total thyroidectomy performed by 1 of 3 surgeons. Interventions According to a randomized sequence, total thyroidectomy was performed in 100 patients using LigaSure and in 100 patients using the clamp-and-tie technique. Main Outcome Measures End points of the study included the comparative evaluation of postoperative complications, need for parathyroid gland autotransplantation, operative time, and time to hospital discharge. Preoperative, postoperative (24 hours), and 6-week follow-up serum Ca ++ levels are also reported and compared. Results The postoperative complication rate was 35% overall, including all transient postoperative disturbances. The incidence of cervical hematomas was 2%, but 3 patients (1.5%), 1 in the LigaSure group and 2 in the clamp-and-tie group, required repeat operations because of respiratory tract obstruction. The incidence of permanent complications was 2.5% overall, including 3 patients (1.5%) with permanent hypocalcemia and 2 patients (1%) with permanent recurrent nerve lesions. No statistical difference in the incidence of complications was found between the 2 study groups. Similarly, no difference was found in mean hospitalization time and need for parathyroid gland autotransplantation. Preoperative, postoperative, and 6-week follow-up mean serum Ca ++ levels were not statistically different in the 2 study groups and in the subset of patients undergoing parathyroid gland autotransplantation. Mean operative time was significantly shorter in the LigaSure group, although the mean difference between the 2 study groups was minimal (7.4 minutes). Concomitantly, there was an additional cost of 45€ (US $57.40) per operation using LigaSure. Conclusion The use of LigaSure is equally as safe and effective at vessel division and homeostasis as the clamp-and-tie technique, with a statistically significant (although minimal) decrease in mean operative time. Because of this minimal decrease in operative time, use of LigaSure would allow more patients to undergo total thyroidectomy each year, which would eventually help to offset its higher cost.

Breast vasculitis presenting as a tumor-like lesion is rare. The differential diagnosis in these cases can be extremely difficult but is very important for treatment and follow-up. We report the case of a 80-year-old woman who was admitted to our service with a lesion resembling an inflammatory carcinoma of the breast. We discuss the pathological and clinical characteristics, the presentation, assessment and treatment of this case and its resolution. Few reports in the literature have addressed the possible occurrence of systemic vasculitis mimicking cancerous lesions. The most common location of such lesions was shown to be the breast in one review. Although rare, such manifestations can be effectively recognized and treated.

We describe a case of gastric carcinoids concomitant with gastric adenocarcinoma in a 50-year-old woman affected by atrophic gastritis. Number and size of the lesions, pathological examinations, and underlying gastric disease all indicated low-risk carcinoids. Nevertheless, when R1 gastrectomy was carried out, an unsuspected lymph node metastasis from carcinoid was found along the lesser curvature. The same occurrence is reported in several cases of the literature, which suggests that the association of gastric carcinoid to adenocarcinoma could point to the malignant nature of carcinoid, apart from underlying gastric disease and tumor characteristics.