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Resume Contexte Le suivi endoscopique apres sleeve gastrectomie (SG) revele parfois des resultats inquietants comme la presence de lesions digestives majeures telles que l’œsophagite, l’œsophage de Barrett (OB), ainsi que le cancer de l’œsophage. Objectifs Le but de cette etude etait d’etudier la frequence et la severite des lesions œsophagiennes et gastriques longtemps apres une SG. Methodes Notre equipe a recueilli les resultats des endoscopies œsogastriques realisees sur des patients ayant eu une SG, cinq ans et plus, auparavant, dans notre institution ; c’est-a-dire d’avril 2010 a aout 2014. Nous avons envoye une prescription d’endoscopie œsogastrique par la poste a tous les patients operes entre ces dates. Les resultats ont ete recueillis de janvier 2018 a juin 2019. Resultats Sur les 765 patients qui ont beneficie d’une SG cinq ans et plus auparavant, seulement 78 (10,2 %) ont accepte d’avoir une endoscopie œsogastrique. L’âge moyen avant la SG etait de 51 ans (extremes : 25–70 ans). L’indice de masse corporelle (IMC) moyen etait de 44,2 ± 4,6 kg/m2. Pour 12 de ces 78 patients (15,4 %), il s’agissait d’une chirurgie de revision : 9 SG apres anneau gastrique, et 3 SG de revision (Re-SG). Avec un suivi moyen de 6,3 ± 0,8 ans, les resultats endoscopiques des 78 patients se sont averes normaux dans 31 cas (39,7 %). Une gastrite a ete trouvee chez 28 patients (35,9 %), une œsophagite de grade C ou D dans 15 cas (19,2 %), une hernie hiatale dans 18 cas (23,1 %), un polype gastrique benin dans 2 cas (2,6 %). Parmi les 28 patients atteints de gastrite, l’Helicobacter Pylori a ete detecte dans 8 cas (28,6 %). Aucun cancer n’a ete diagnostique, un OB apres SG a ete trouve dans un seul cas (1,3 %) (endoscopie normale avant la SG). Six des 15 patients atteints d’œsophagite (40 %) avaient des symptomes de reflux. Quatorze de ces patients (93,3 %) ont developpe une œsophagite de novo. Conclusion Seulement 10,2 % des patients operes ont accepte d’avoir une endoscopie œsogastrique de controle, a long terme, apres SG. La frequence et la severite des anomalies observees, avec un suivi moyen de plus de 6 ans, plaident pour une strategie d’endoscopies œsogastriques systematiques de controle, et a long terme, apres SG.

Gastric sleeve stenosis (GSS) is described in 1%-4% of patients.To evaluate the role of endoscopy in the management of stenosis after laparoscopic sleeve gastrectomy using a standardized approach according to the characteristic of stenosis.Retrospective, observational, single-center study on patients referred from several bariatric surgery departments to an endoscopic referral center.We enrolled 202 patients. All patients underwent endoscopy in a fluoroscopy setting, and a systematic classification of the type, site, and length of the GSS was performed. According to the characteristics of the stenosis, patients underwent pneumatic dilatation or placement of a self-expandable metal stent or a lumen-apposed metal stent. Failure of endoscopic treatment was considered an indication for redo surgery, whereas patients with partial or complete response were followed up for 2 years. In the event of a recurrence, a different endoscopic approach was used.We found inflammatory strictures in 4.5% of patients, pure narrowing in 11%, and functional stenosis in 84.5%. Stenosis was in the upper tract of the stomach in 53 patients, whereas medium and distal stenosis was detected in 138 and 11 patients, respectively, and short stenosis in 194 patients. A total of 126 patients underwent pneumatic dilatation, 8 self-expandable metal stent placement, 64 lumen-apposed metal stent positioning, and 36 combined therapy. The overall rate of endoscopy success was 69%.GSS should be considered to be a chronic disease, and the endoscopic approach seems to be the most successful treatment, with a prolonged positive outcome of 69%. Characteristics of the stenosis should guide the most suitable endoscopic approach. (Surg Obes Relat Dis 2022;X:XXX-XXX.) © 2022 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Resume Situation La sleeve gastrectomie laparoscopique (SGL) et le bypass gastrique en Y laparoscopique (BPGYL) sont couramment effectues, mais peu d’etudes ont montre la superiorite d’une strategie par rapport a l’autre. Objectif Comparer simultanement la SGL et le BPGYL en termes de perte de poids et de morbi-mortalite sur une periode de suivi de 36 mois. Methodes Etude prospective et comparative entre la SGL et le BPGYL. L’objectif principal de cette etude etait une hypothese conjointe testee au cours d’un suivi de 36 mois : le premier critere principal concernait la frequence de patients presentant une perte d’exces de poids (PEP) superieure a 50 % (% PEP > 50 %) apres SGL et BPGYL ; le deuxieme critere principal etait un critere composite defini comme la survenue d’au moins une complication majeure. Les objectifs secondaires devaient rapporter la regression des comorbidites et l’amelioration de la qualite de vie. Resultats Deux cent soixante dix-sept patients ont participe a l’etude (91 BPGYL, 186 SGL). L’âge moyen etait de 41,1 ± 11,1 ans, et l’indice de masse corporelle preoperatoire moyen de 45,3 ± 5,5 kg/m2. Apres 36 mois, le % PEP > 50 % n’etait pas inferieur dans le groupe SGL (82,2 %) par rapport au groupe BPGYL (82,1 %) ; pendant que le taux de complications majeurs etait significativement plus eleves apres BPGYL (15,4 %) qu’apres SGL (5,4 %, p = 0,005). Apres 36 mois, les objectifs secondaires etaient comparables entre les groupes alors que le reflux gastro-œsophagien (RGO) a augmente dans le groupe SGL et a diminue dans le groupe BPGYL. Conclusions La SGL a ete non inferieure au BPGYL pour ce qui concerne la perte de poids et etait associee a un taux plus faible de complications majeures au cours d’un suivi de 3 ans. Mais le RGO a augmente dans le groupe SGL et a diminue dans le groupe BPGYL.

Objectif : La chirurgie bariatrique est le traitement le plus efficace pour la réduction de poids à long terme chez les patients souffrant d’obésité pathologique. Il existe une abondante littérature et des croyances liant les causes d’échec de perte de poids aux aspects techniques ou hormonaux, mais aussi aux aspects alimentaires, ou au style de vie sédentaire. Méthodes : Nous avons envoyé aux patients un autoquestionnaire simple pour évaluer l’observance des conseils nutritionnels ou d’activité physique donnés par notre équipe au cours de la période préopératoire. Les patients ayant reçu le questionnaire ont bénéficié d’une chirurgie bariatrique de septembre 2013 à août 2016. Les questionnaires ont été recueillis lors d’une réunion annuelle de suivi en septembre 2017. Cent quarante-quatre patients sur 750 ont répondu à ce questionnaire et 133 avaient eu une sleeve gastrectomie par laparoscopie. Résultats : Soixante-quatre pour cent des patients avaient une activité physique qui durait moins de 30 minutes par jour. Parmi les patients, 46 % ont déclaré une faim anormale, 60 % avaient terminé leur repas en moins de 20 minutes, 18,7 % avaient une consommation régulière de chewinggum, 32 % avaient plus de trois collations par semaine, 66 % avaient une consommation excessive de sucre plus de deux fois par semaine et 18 % moins de trois repas par jour. Le genre féminin, une durée de repas inférieure à 20 minutes, et moins de trois repas par jour étaient significativement liés à une perte d’IMC plus faible, 13,4 vs 15,8 kg/m2, p = 0,0049 ; 13,5 vs 14,3 kg/m2, p = 0,0002 ; 12,2 vs 14,3 kg/m2, p = 0,0307 respectivement. Conclusion : Le genre féminin, une alimentation rapide et moins de trois repas par jour sont associés à une perte de poids plus faible chez les patients ayant bénéficié d’une chirurgie bariatrique il y a plus de deux ans.

Summary Background Endoscopic follow-up after sleeve gastrectomy (SG) sometime reveals worrisome findings as the presence of major digestive lesions such as esophagitis, Barrett's esophagus (BE), and also esophageal cancer. Objectives The aim of this study was to investigate the frequency and severity of esophageal and gastric lesions after SG. Methods Our team collected the results of esogastric endoscopies performed on patients who underwent SG up to five years before in our hospital, from April 2010 to August 2014. Summons were sent by mail to all patients operated on between those dates. The results were collected from January 2018 to June 2019. Results Of the 765 patients who underwent SG up to five years before, only 78 (10.2%) agreed to undergo an upper digestive endoscopy. The average age before surgery was 51 years (range: 25–70 years). The mean preoperative body mass index (BMI) was 44.2 ± 4.6 kg/m2. For 12 out of these 78 patients (15.4%) it was revisional surgery: 9 SG after gastric banding, and 3 revisional SG (Re-SG). With an average follow-up of 6.3 ± 0.8 years, the endoscopic results of the 78 patients were found to be normal in 31 cases (39.7%): gastritis was found in 28 patients (35.9%), severe grade C or D esophagitis was found in 15 cases (19.2%), hiatal hernia in 18 cases (23.1%), a benign gastric polyp in 2 cases (2.6%). Of the 28 patients with gastritis, Helicobacter Pylori was detected in 8 cases (28.6%). No cancer was diagnosed, and BE after SG was found in only one case (1.3%) (normal before surgery). Six of 15 patients with esophagitis (40%) had reflux symptoms. Fourteen of these patients (93.3%) developed de novo esophagitis. Conclusion Only 10.2% of operated patients agreed to a long-term esogastric endoscopy. The frequency and severity of endoscopic anomalies observed with an average follow-up of more than 6 years pleads for a policy of systematic upper endoscopies of long-term control after SG.

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.

Resume Face a l’emergence de la pandemie a COVID 19, l’activite de chirurgie bariatrique/metabolique a ete arretee. Le confinement et l’arret de cette chirurgie ont eu un impact sous-estime sur la population obese avec prise de poids, et aggravation des comorbidites. Un certain nombre de candidats a cette chirurgie sont exposes a un risque important de mortalite liee a la pandemie. En effet, l’obesite et le diabete sont deux facteurs de risque majeurs de forme grave d’infection a COVID-19. Le seul traitement efficace actuel de l’obesite est la chirurgie metabolique avec un benefice rapide et durable. Il parait donc necessaire de reprendre une activite de chirurgie metabolique. Le but de ce travail est de hierarchiser la reprise chirurgicale afin qu’elle soit progressive et coherente. Les organigrammes proposes aideront les centres a determiner les patients prioritaires selon la balance benefice-risque. Le diabete a une place centrale dans l’arbre decisionnel. Les modalites de reprise seront variables d’un centre a l’autre selon les ressources humaines, materielles et medicamenteuses, et seront a adapter a l’evolution epidemique. Un consentement eclaire specifique sera necessaire. Un depistage chez les patients obeses est a envisager dont les modalites de depistage sont elaborees sur la base des connaissances disponibles. En cas de suspicion de COVID, la chirurgie doit etre differee. Il faut insister sur les mesures et gestes barrieres afin de proteger le patient et le personnel soignant. Un confinement est fortement suggere pour le patient durant le premier mois postoperatoire. Le suivi des patients sera effectue de preference par teleconsultation.

Background: Submucosal tumors (SMTs) of the gastrointestinal tract are a rare pathological entity comprising a wide variety of neoplastic and non-neoplastic lesions. Even if most SMTs are benign tumors (e.g., leiomyomas), a smaller portion may have a malignant potential (e.g., gastrointestinal stromal tumor (GIST)). Preoperative diagnosis of SMT in bariatric patients may arise challenging clinical dilemmas. Long-term surveillance may be difficult after bariatric surgery. Moreover, according to SMT location, its presence may interfere with planned surgery. Submucosal tunneling endoscopic resection (STER) has emerged as an effective approach for minimally invasive en bloc excision of SMTs. This is the first case series of STER for SMTs before bariatric surgery. Methods: Seven female patients underwent STER for removal of SMTs before bariatric surgery. All lesions were incidentally diagnosed at preoperative endoscopy. STER procedural steps comprised mucosal incision, submucosal tunneling, lesion enucleation, and closure of mucosal defect. Results: En bloc removal of SMT was achieved in all cases. Mean procedural time was of 45 min (SD 18.6). No adverse event occurred. Mean size of the lesions was 20.6 mm (SD 5.8). Histological diagnoses were 5 leyomiomas, 1 lipoma, and 1 low grade GIST. Bariatric procedure was performed after a mean period of 4.1 months (SD 1.6) from endoscopic resection. Conclusion: STER is a safe and effective treatment for the management of SMT even in bariatric patients awaiting surgery. Preoperative endoscopic resection of SMTs has the advantages of reducing the need for surveillance and removing lesions that could interfere with planned surgery. STER did not altered accomplishment of bariatric procedures.

Summary Background Plasma citrulline is currently used in clinical practice as a marker of small bowel functional mass. Behaviour of plasma citrulline after bariatric surgery and its link with post-operative outcome are still poorly understood. Objective Primary objective was to compare plasma citrulline 12 months after two types of bariatric surgery with pre-operative concentrations. Secondary objectives were to search for correlation between plasma citrulline variation and body weight and fat mass loss. Design This is an ancillary study of the BARIASPERM study. Forty-six adult men (mean age 38.9 ± 7.9 years) who underwent gastric bypass (GB, n = 20) or sleeve gastrectomy (SG, n = 26) were included in this prospective study. Plasma citrulline was measured at baseline, 6 months and 12 months after surgery, as well as total body weight and fat mass measured by dual x-ray absorptiometry (DEXA). Results Plasma citrulline increased significantly 12 months after surgery, both after gastric bypass and sleeve gastrectomy (respectively 30.2% [18.3–42.2] and 17.8% [5.8–29.7]). The increase was significantly higher after GB than after SG (p = 0.02) while total body weight and fat mass loss were not significantly different between GB and SG. The increase in plasma citrulline levels tended to be positively correlated with both weight and fat mass loss however the association did not reach statistical significance (p = 0.07 and p = 0.06 respectively). Conclusion These results confirm the increase in plasma citrulline after GB published in two previous small studies. Citrulline also significantly increased after SG, and in spite of similar weight loss obtained with both surgery types, citrulline increase was higher after GB than SG. This suggests different modifications of intestinal functional mass after these two different techniques.

Highlights • Nutritional status in a pregnant woman is crucial. It determines the fetal outcome. • We added a case of spina bifida after Omega Gastric Bypass. • Biochemical and ultrasound monitoring should be performed regularly in pregnant women with a history of bariatric surgery. • Vitamins, minerals and trace metals deficiencies after bypass bariatric surgery could be prevented by adequate supplementation administered before and during pregnancy., Introduction Bariatric surgery has been increasingly popular during the last years because of its proven efficacy on obesity and related complications. However, nutrient deficiency is common after surgery, in particular after Roux-en-Y gastric bypass (RYGB) or omega gastric bypass (OGB), due to iatrogenic malabsorption. All vitamins and minerals could be involved, including vitamin B9 which plays an important role in the prevention of neural tube defects during pregnancy. We present a case of a spina bifida in the fetus of a pregnant woman following OGB. Case presentation A twenty-six years old young woman underwent OGB five years after weight loss failure post sleeve gastrectomy. Her initial body mass index (BMI) was 42.7 kg/m2. Two years after OGB, she became pregnant. On her gynecologist’s advice, the patient discontinued daily vitamin intake before the end of the first trimester, as obstetrical follow-up had been considered appropriate. Regrettably, second trimester ultrasound showed myelomeningocele and surgical abortion was decided during the 25th week of pregnancy. Discussion Nutritional status in a pregnant woman is crucial, since it determines the fetal outcome. Biochemical and ultrasound monitoring should be performed regularly, especially in pregnant women with a history of bariatric surgery. Conclusion Vitamins, minerals and trace metals deficiencies after bypass bariatric surgery could be prevented by adequate supplementation administered before and during pregnancy.

Introduction : La crise sanitaire liée au Covid-19 a engendré un confinement de la population générale afin de limiter la propagation du virus. Dans l’émergence de cette nouvelle maladie, il a fallu se mobiliser afin de limiter la transmission du virus auprès de notre population d’obèses, à risque de développer une forme grave au Covid-19. Pour cela, nous avons propos de réaliser nos ateliers ETP par visioconférence à l’ensemble des patients inclus dans le programme ETP « chirurgie bariatrique ». Objectifs : L’objectif de cette étude est de dégager les bénéfices et inconvénients de ce format d’ETP distanciel en collectif, leur efficience au regard des apprentissages et des changements de comportement, et les différentes ressources du programme facilitant leurs apprentissages pour le parcours pré et post chirurgie. Méthodes : Il s’agit d’une étude mixte en deux phases. La première phase de l’étude consiste en une étude qualitative exploratoire par entretiens semi-directifs auprès de 18 patients ayant suivi l’ETP en distanciel de mars 2020 à mai 2020, pour explorer leur vécu des différentes sessions éducatives. L’étude exploratoire a permis d’élaborer dans une deuxième phase un questionnaire pour recueillir le point de vue de l’ensemble des patients éduqués de mars 2020 à mai 2021. L’analyse des réponses a mobilisé la théorie des capabilités pour identifier les facteurs de conversion positifs ou négatifs du programme pour les apprentissages des patients. Résultats : Sur l’ensemble des 70 patients inclus quarante-trois personnes ont répondu au questionnaire… Cette ETP en visioconférence a permis de maintenir la programmation des interventions chirurgicales. Les patients ont rapporté un gain de temps lié à l’absence de déplacement. Des patients avec une faible littératie numérique ont pu accéder à ce programme. Les participants ont souligné l’importance de la continuité du lien avec les soignants. Les patients ont rapporté des compétences d’auto-soins acquises à travers cette ETP à distance ainsi qu’une perte de poids de 7 kg en moyenne. Des facteurs positifs et négatifs au regard des apprentissages ont été mis en évidence. Discussion : Les résultats de cette étude démontrent l’intérêt de développer des programmes e-ETP pour plusieurs raisons : les difficultés à faire venir ces patients à l’hôpital, les inégalités géographiques d’accès à l’ETP, l’absence de remboursement des titres de transport et d’espaces disponibles dédiés. Il parait donc important de former les professionnels et les patients à l’outil numérique. Conclusion : Cette étude auprès de la population de patients obèses ayant participé à un programme d’ETP par visioconférence en période de pandémie et de confinement témoigne de la qualité perçue de cette éducation en distanciel. Au regard des différents programmes transposés sous format distanciel, il serait intéressant de promouvoir des recherches croisant les expériences des patients et des professionnels pour proposer aux autorités de santé le meilleur format éducatif.

Highlights • Literature evidences regarding the evolution of Barrett’s esophagus after sleeve gastrectomy is poor and the relation between sleeve gastrectomy and the development of subsequent esophageal cancer isn’t clear yet. • Preoperative upper endoscopy should be performed in order to detect gastroesophageal reflux disease, Barrett’s esophagus, before undergoing bariatric surgery. Post operative monitoring of the upper gastrointestinal tract after sleeve gastrectomy is essential., Introduction : Sleeve gastrectomy (SG) has become one of the most dramatically increasing bariatric procedures worldwide due to its excellent results and impact on the obesity pandemic. Morbid obesity is known to increase the risk of esophageal adenocarcinoma. However, the evolution of gastroesophageal reflux disease (GERD) along with Barrett’s esophagus (BE) after SG is of concern since there is little data available. We present a case of esophageal adenocarcinoma after SG with known intestinal metaplasia on preoperative gastroscopy. Case presentation : We report a case of a 55 years old female patient who presented lower esophageal adenocarcinoma three years after complicated SG with known preoperative BE without dysplasia detected by gastroscopy. Multidisciplinary decision suggested treatment by endoscopic mucosectomy. The endoscopic control at one year did not highlight tumoral recurrence but still BE without dysplasia. Discussion : Literature review regarding the evolution of BE after SG is poor and the relation between SG and the development of subsequent esophageal cancer isn’t clear yet. Conclusion : Preoperative endoscopy should be performed in order to detect GERD, BE, and potential carcinomas of the upper gastrointestinal tract before undergoing bariatric surgery. The long-term monitoring after SG is essential.

Background A large number of patients who undergo laparoscopic sleeve gastrectomy present with surgical complications. Stenosis, in particular, occurs in .7%–4% of cases. Objectives To report our experience, results, and long-term follow-up after pneumatic dilation of late functional helix stenosis after laparoscopic sleeve gastrectomy. Setting Multicenter study led by an endoscopic tertiary referral center. Methods Thirty-five patients were dilated initially at 30 mm. Thirteen out of 35 patients underwent a second dilation up to 35 mm. Only 8 patients underwent a third pneumatic dilation up to 40 mm. The stricture was localized in the mid-body of the sleeve in 32 patients overall; 3 had narrowing adjacent to the cardia. Eleven twists formed an acute angle between the 2 segments of the stomach, whereas 24 angles were obtuse. Seven out of 35 patients presented with persistent dilated pouch above the twist. Two patients were lost to follow-up. Overall outcome at an average follow-up of 15.5 months after primary surgery (range 7–49 mo) was as follows: 12 clinical failures and 1 technical failure (40%) and 60% (20 out of 33) clinical success. Conclusion Pneumatic dilation of late functional helix stricture is an effective technique for treatment of dysphagia in the majority of patients treated. Complete helix stricture, defined in function of the angle within twist, as well as the presence of a persistently dilated gastric pouch above the kinking, seems to be correlated with higher failure rates.

Plusieurs etudes notent une amelioration de l’embauche apres la chirurgie bariatrique de 17 a 29 %. Nous avons analyse la relation du taux d’emploi avec la perte de poids, la satisfaction generale et le score de precarite 2,3 ± 0,1 ans apres une chirurgie bariatrique dans une region touchees par un fort a taux de chomage. 791 patients ont recu un auto-questionnaire evaluant la precarite (score EPICES), l’emploi, la satisfaction et le score BAROS. Ceux ci ont ete collectes lors de leur suivi (septembre 2018). 133 patients ont repondu. L’âge moyen des patients etait de 45 ans, avec 88 % de femmes et un index de Masse Corporel (IMC) moyen initial de 42,7 kg/m2, 88 % avaient une gastrectomie longitudinale. La perte moyenne d’IMC etait de 12 ± 0,5 kg/m2. Les moyennes des scores EPICES, BAROS et echelle de satisfaction etaient respectivement de 31,9 ± 18, 1,3 ± 1,1 et 4,27 ± 1. 19 sujets ont obtenu un emploi apres chirurgie. Avant la chirurgie, 60 % avaient un emploi et 72 % apres. Une analyse multivariee, comparant les employes aux chomeurs (77 vs 52) a revele de meilleurs scores dans l’aspect physique/social de l’echelle de satisfaction BAROS. L’emploi des patients apres une chirurgie bariatrique semble etre independant de l’IMC, de la perte de poids, de la precarite ou de l’âge par rapport a ceux qui restent sans emploi. En conclusion, la chirurgie bariatrique est associee a un meilleur taux d’emploi sans relation avec la perte de poids ni la precarite.

Le suivi endoscopique apres une chirurgie bariatrique, et en particulier apres une gastrectomie longitudinale (GL) revele parfois des lesions digestives inquietantes telles que l’œsophagite, l’endobrachyoesophage (EBO), et le cancer de l’œsophage. Le but de ce travail etait d’etudier la frequence et la gravite de ces lesions apres chirurgie. Nous avons collecte les resultats des endoscopies œsogastriques realisees sur des patients ayant beneficie d’une chirurgie bariatrique jusqu’a cinq ans auparavant (avril 2010-aout 2014). Des prescriptions ont ete envoyees a tous ces patients. Nous avons compare ces resultats avec les donnees endoscopiques preoperatoires. Sur les 820 patients ayant eu une chirurgie bariatrique, seuls 84 (10,2 %) ont accepte de faire une endoscopie digestive haute 6,4 ± 0,9 ans apres. L’âge moyen etait de 52 ans (extremes : 23-70 ans). L’indice de masse corporelle (IMC) preoperatoire moyen etait de 44,4 ± 4,8 kg/m2. Soixante-quinze (89,2 %) des 84 patients ont eu une GL. Les resultats endoscopiques se sont reveles : normaux dans 36,9 %, gastrite dans 35,7 %, (1 ulcere). Une œsophagite severe a ete retrouvee dans 17,8 %. Aucun cancer n’a ete diagnostique, et seul un EBO post GL a ete identifie (1,2 %). Tous les patients atteints d’œsophagite avaient eu une GL et 93,3 % l’ont developpee de novo. Seulement 10,2 % des patients operes ont accepte une endoscopie œsogastrique a long terme. La frequence et la severite des anomalies endoscopiques observees avec un recul moyen de plus de 6 ans plaident pour une politique d’endoscopies systematiques a long terme apres chirurgie bariatrique et surtout apres GL.

Summary Background Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en Y gastric bypass (LRYGB) are commonly performed, but few studies have shown superiority of one strategy over the other. Objective Simultaneously compare LSG and LRYGB in terms of weight loss and morbimortality over a 36-month follow-up period. Setting University hospital and bariatric surgery centers, France. Methods Prospective, comparative study between LSG and RYGBP. The primary endpoint of this study was a joint hypothesis during the 36-month follow-up: the first primary outcome pertained to the frequency of patients with an excess weight loss (EWL) greater than 50% (% EWL > 50%) after LSG or RYGB; the second primary outcome was defined as a composite endpoint of at least one major complication. Secondary objectives were regression of comorbidities and improvement in quality of life. Results Two hundred and seventy-seven patients were included (91 RYGBP, 186 LSG). The mean age was 41.1 ± 11.1 years, and average preoperative body mass index of 45.3 ± 5.5 kg/m2. After 36 months, the %EWL > 50% was not inferior in the case of LSG (82.2%) relative to LRYGB (82.1%); while major complications rates were significantly higher in LRYGB (15.4%) vs. LSG (5.4%, P = 0.005). After 36 months, all secondary objectives were comparable between groups while only gastroesophageal reflux disease (GERD) increased in LSG group and decreased in LRYGB group. Conclusions LSG was found non-inferior to LRYGB with respect to weight loss and was associated with lower risk of major complications during a 3-year follow-up. But GERD increased in LSG group and decreased in LRYGB group.

Aim To report the results of surgery for obstructive right colon cancer (ORCC) and to identify risk factors associated with worse outcomes that may help surgeons to choose the best surgical option. Methods This is a retrospective national cohort study, including all patients operated on for ORCC from 2000 to 2015. Those treated with colonic stent or symptomatic treatment were excluded. We described outcomes after surgery for ORCC and performed multivariate analyses for mortality, morbidity and survival. Results Among 776 patients analyzed, 716 (92%) had their primary tumor removed, with primary anastomosis in 582 (82%). The remaining 194 underwent anastomosis with loop ileostomy (n = 21), resection with double-end stoma (n = 113), defunctioning stoma without resection (n = 48) and ileocolic by-pass (n = 12). Postoperative mortality, morbidity and anastomotic leak rates were 10%, 51% and 14%, respectively. In multivariate analysis, age >70, ASA score ≥3 and hemodynamic instability were predictors of postoperative mortality whereas ASA score ≥3, hemodynamic instability and intra-operative complications were predictors of severe morbidity. No factors were correlated with anastomotic leak. After a median follow-up of 26 months, 8% of patients were alive with a permanent stoma. Five-year overall, disease-free and cancer-specific survival was 42%, 42% and 62%, respectively. In multivariate analysis, peritonitis, synchronous metastases and absence of adjuvant chemotherapy were predictors of decreased overall survival. Conclusions Emergency surgery for ORCC is associated with high mortality and morbidity. Two third of patients with ORCC can be managed with resection and primary anastomosis. For high-risk patients, a staged surgical management may be discussed.

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

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

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

But Evaluer l’amelioration de la qualite de vie constatee entre sleeve gastrectomie (SG) et by-pass gastrique (BPG) 36 mois apres l’intervention. Methode Le questionnaire « Medical Outcome Study Short Form–36 » (MOS SF-36) a ete soumis a tous les patients participants a une etude prospective comparant SG et BPG. Tous les domaines (sante physique, sante mentale) et echelles (activite physique, limitations dues a l’etat physique, douleurs physiques, sante percue, vie et relation avec les autres, sante psychique, limitations dues a l’etat psychique, evolution de la sante percue) du MOS SF-36 ont ete evalues en preoperatoire et a 36 mois. Resultats Les questionnaires ont ete soumis a 277 patients. Seuls 153 (55 %) les ont completement remplis en preoperatoire et a 36 mois. Il s’agissait de 94 SG et 59 BPG. Les 2 procedures ont permis d’obtenir une perte de poids semblable a 36 mois. Tous les domaines et echelles ont ete significativement ameliores a 36 mois mais il n’a pas ete constate de difference entre SG et BPG. Conclusions Trente-six mois apres SG ou BPG, la qualite de vie etait nettement amelioree et il n’a pas ete constate de difference entre les deux procedures chirurgicales.

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

Resume But de l’etude Evaluer l’efficacite et la securite de la sleeve gastrectomie (SG) 5 annees revolues apres sa realisation. Patients et methodes De juin 2005 a janvier 2007, 65 patients obeses ont eu une SG. 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 5 ans revolus apres la SG d’apres un questionnaire soumis aux patients par un des auteurs (IB), de mai 2011 a fevrier 2012. Resultats Un recueil complet des donnees a ete obtenu pour 53 patients (82 %), incluant 45 patients ayant eu une SG comme seul traitement chirurgical, et 8 patients qui ont eu une seconde intervention bariatrique, dans un deuxieme temps, du fait d’une insuffisance de perte de poids (5 by-pass gastriques, 3 re-SG). Pour ces 53 patients, nous avons constate une PEP moyenne de 54,4 % a 2 ans et 53,7 % a 5 ans ; une PEI moyenne de 61 % a 2 ans et 60 % a 5 ans. Trois patients (5,7 %) ont presente une complication dans les 30 jours postoperatoires (2 fistules [3,8 %], 1 hemorragie [1,9 %]). Trois patients (5,7 %) ont presente une eventration sur site de trocart operee 10 a 34 mois apres la SG. L’analyse des resultats du groupe des 45 patients ayant eu exclusivement une SG a montre une PEP moyenne de 57,1 % a 2 ans, et 50,7 % a 5 ans ; une PEI moyenne de 64 % a 2 ans et 56,8 % a 5 ans. Parmi ces 45 patients, 13 (28,9 %) avaient un traitement antidiabetique avant la SG et 5 (11,1 %), 5 ans apres la SG (diminution de 61,5 %) ; 18 (40 %) avaient un traitement antihypertenseur avant la SG, et 8 (17,8 %) 5 ans apres (diminution de 55,5 %) ; 12 (26,7 %) avaient un traitement hypolipemiant avant la SG, et 5 (11,1 %) 5 ans apres (diminution de 58,3 %) ; 24 (53,3 %) avaient un SAS avant la SG et 6 (17,8 %) 5 ans apres (diminution de 75 %). Par ailleurs, 5 patients (11,1 %) avaient un RGO traite par IPP avant la SG, et 15 (33,3 %) 5 ans apres (augmentation de 200 %). Conclusion Cinq annees revolues apres une SG, la perte de poids etait satisfaisante, peu de complications ont ete constatees, la diminution des comorbidites a ete importante, mais la frequence du RGO augmentee.

Situation La sleeve gastrectomie (SG) par voie laparoscopique a ete consideree comme le premier temps d’une prise en charge chirurgicale bariatrique en deux temps, pour des patients a haut risque operatoire. Plus recemment, la SG a ete envisagee comme une intervention definitive de l’obesite pathologique avec des resultats a court et moyen terme satisfaisants.

Objective. This prospective study evaluated laparoscopic sleeve gastrectomy for its safety and efficiency in excess weight loss (%EWL) in super superobese patients (BMI>60 Kg/m2).Results. Thirty patients (33 women and 7 men) were included, with mean age of 35 years (range 18 to 59). Mean preoperative BMI was 66 Kg/m2(range 60 to 85). The study included one patient with complete situs inversus and 4 (14%) with previous restrictive gastric banding. The mean operative time was 120 minutes (range 80 to 220 min) and the mean hospital stay was 7.5 days (4 to 28 days). There was no postoperative mortality or need for a laparotomy conversion. Two subphrenic hematomas, one gastric fistula, and one pulmonary embolism, were the major complications. After 18 months 17 (77%) had sufficient weight loss and six had insufficient results, leading to either re-sleeve gastrectomy (3), or gastric bypass (2). Three years after the initial laparoscopic sleeve gastrectomy, the mean EWL was 51% (range 21 to 82).Conclusion. The laparoscopic sleeve gastrectomy is a safe and efficient operating procedure for treating super superobesity. In the case of insufficient weight loss, a second-stage operation like resleeve gastrectomy or gastric bypass can be proposed.

Objectif Evaluation des resultats de la sleeve gastrectomie (SG) laparoscopique chez 30 patients supersuperobeses (IMC > 60 kg/m2).

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

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

Les patients obeses ont une prevalence elevee de pathologies cardiaques et pulmonaires, qui peuvent etre connues ou meconnues, lors de la prise en charge pour chirurgie de l’obesite. Le but de cette etude a ete d’evaluer la pertinence des explorations cardiaques et pulmonaires, effectuees en routine, avant une intervention bariatrique par pose d’anneau gastrique. Nous avons etudie une population composee de 67 femmes et de dix hommes, âges de 39 ± 10 ans (m ± SD), avec un indice de masse corporelle de 43 ± 10 kg/m 2 (m ± SD). Tous les patients, candidats a une chirurgie de l’obesite ont eu : un electrocardiogramme (ECG), une echocardiographie cardiaque, un test de somnolence d’Epworth, une polysomnographie, une spirometrie, des gaz du sang, et une radiographie de thorax. L’ECG a montre des anomalies de la conduction ou de la repolarisation chez 48 patients (62 %). L’allongement de l’intervalle QT a ete constate chez 13 patients (17 %), mais n’a ete responsable d’aucune contre-indication a une chirurgie de l’obesite. Les tests d’effort etaient negatifs chez 56 patients (73 %) et ont ete ininterpretables chez les 21 autres (27 %), les epreuves etant sous-maximales. L’echocardiographie a montre une hypertrophie de la paroi du ventricule gauche anterieure chez 47 patients (61 %). Cela n’a pas modifie les indications operatoires. La polysomnographie a revele un syndrome d’apnee-hypopnee obstructive du sommeil (SAOS) chez 31 patients (40 %), conduisant a un traitement par ventilation sous pression positive continue (VPPC) chez 17 patients (22 %). L’echelle de somnolence d’Epworth etait pathologique chez seulement 17 patients (22%). Dix patients (13%) ont presente des radiographies de thorax avec des alterations mineures. La spirometrie a montre un syndrome obstructif chez 13 patients (17 %) et un syndrome restrictif chez cinq patients (6 %). Une hypoxemie inferieure a 80 mmHg a ete observee chez 21 patients (27 %), et une hypercapnie superieure a 45 mmHg a ete observee chez six patients (8 %), sans aucune consequence sur la gestion de la periode perioperatoire. Les explorations cardiorespiratoires preoperatoires peuvent etre divisees en trois groupes : le premier, celui des explorations non informatives, comprenant le test d’effort et l’echelle de somnolence d’Epworth ; le deuxieme, celui des explorations informatives, comprenant la radiographie de thorax, l’ECG, l’echographie cardiaque, la spirometrie, les gaz du sang ; est a part, la polysomnographie, qui est informative et pertinente, car elle peut entrainer une modification de la prise en charge pre et postoperatoire.

Key points 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.

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

The prevalence of obesity is increasing in the socioeconomically deprived sector of the French population.Our objective was to assess whether the presence of a socioeconomic gradient could affect access to bariatric surgery in a publicly funded healthcare system with full medical expense coverage.The study was conducted at a general hospital and a health examination center.We prospectively included 100 patients who were admitted to the hospital for a preoperative bariatric surgery evaluation. As a reference group, we included 578 patients from the same area with body mass index (BMI) values≥35 kg/m² who visited the health center for regular medical, cardiovascular checkups. The patients were required to complete the Evaluation of Precariousness and Health Inequalities in Health Examination Centers (EPICES) questionnaire to investigate deprivation (deprivation cutoff≥30.17).A total of 94 patients had complete data, with a mean EPICES score of 37.7±19.1 (P.001). Patients were younger (mean age 39.2±12.7 years, P.001), had a stronger female predominance (87%, P = .030), and higher mean BMI (43.3±6.9 kg/m², P.001) than the reference group and were less socioeconomically deprived (64% versus 82% in the reference group, P.001). No significant correlations existed among BMI, participant age, and deprivation score. In a subsequent age- and BMI-matched analysis, bariatric surgery candidates exhibited lower levels of deprivation.The presence not only of material (e.g., coverage for medical expenses) but also social support is an important step toward the acceptance of bariatric surgery by morbidly obese patients.

Leaks are considered one of the major complications of laparoscopic sleeve gastrectomy (LSG) with a reported rate up to 7 %. Drainage of the collection coupled with SEMS deployment is the most frequent treatment. Its success is variable and burdened by high morbidity and not irrelevant mortality. The aim of this paper is to suggest and establish a new approach by endoscopic internal drainage (EID) for the management of leaks. Since March 2013, 67 patients presenting leak following LSG were treated with deployment of double pigtail plastic stents across orifice leak, positioning one end inside the collection and the other end in remnant stomach. The aim of EID is to internally drain the collection and at the same time promote leak healing. Double pigtails stent were successfully delivered in 66 out of 67 patients (98.5 %). Fifty patients were cured by EID after a mean time of 57.5 days and an average of 3.14 endoscopic sessions. Two died for event not related to EID. Nine are still under treatment; five failure had been registered. Six patients developed late stenosis treated endoscopically. EID proved to be a valid, curative, and safe mini-invasive approach for treatment of leaks following SG. EID achieves complete drainage of perigastric collections and stimulates mucosal growth over the stent. EID is well tolerated, allows early re-alimentation, and it is burdened by fewer complications than others technique. Long-term follow-up confirms good outcomes with no motility or feeding alterations.

Resume Interet du travail La gastrectomie longitudinale, ou “sleeve gastrectomy”, est une technique restrictive avec reduction de la capacite gastrique de 75%. Nous rapportons notre experience chez 4 patientes super super obeses (indice de masse corporelle “IMC”; > 60 kg/m2. Methodes Quatre patientes avec une super super obesite ont eu une gastrectomie longitudinale. Leur poids preoperatoire moyen etait de 173 kg (extremes de 147 a 190 kg), et l’IMC moyen de 65 kg/m2 (extremes de 61 a 67 kg/m2. Resultats Le suivi postoperatoire moyen a ete de 6 mois (extremes de 2 a 12 mois). La perte de poids moyenne a 6 mois a ete de 40 kg (extremes de 20 a 60 kg). La chute moyenne de l’IMC a 6 mois a ete de 16,3 kg/m2 (extremes de 6 a 23 kg/m2. Nous avons constate une complication postoperatoire chez une seule patiente (abces sous-phrenique traite par drainage). Perspectives La gastrectomie longitudinale est associee a peu de complications perioperatoires, et est rapidement efficace sur la super super obesite morbide. Les resultats a long terme doivent etre evalues. Voir aussi dans ce numero l’editorial de Boyan Christoforov, Patients obeses : quelle place pour la chirurgie bariatrique ? p. 371-2.

Background Intraoperative cholangiography and laparoscopic ultrasonography are both used in the detection of common bile duct stones at laparoscopic cholecystectomy. The aim of this prospective study was to determine whether laparoscopic ultrasonography has an alternative or a complementary role with respect to cholangiography in achieving this end. Methods The biliary trees of 900 patients undergoing laparoscopic cholecystectomy were examined routinely by the two methods. The diagnostic power of each investigation and of the two techniques in combination was evaluated. The statistical non-random concordance between the two methods was also determined. Results Laparoscopic ultrasonography was performed in all 900 patients. Cholangiography was performed in 762 (85 per cent). The mean (range) duration was 9·8 (4–21) min for laparoscopic ultrasonography and 17·6 (7–42) min for cholangiography. For the detection of common bile duct stones, with a kappa coefficient of 0·57 (95 per cent confidence interval (c.i.) 0·43 to 0·71), the non-random concordance between the two methods was considered to be fair to good. The sensitivity of laparoscopic ultrasonography was 0·80 (95 per cent c.i. 0·65 to 0·91) and its specificity was 0·99 (95 per cent c.i. 0·98 to 1·00). The respective values for cholangiography were 0·75 (95 per cent c.i. 0·59 to 0·87) and 0·99 (95 per cent c.i. 0·98 to 1·00). The examinations combined had a sensitivity of 0·95 (95 per cent c.i. 0·86 to 0·99) and a specificity of 0·98 (95 per cent c.i. 0·96 to 1·00). Conclusion Laparoscopic ultrasonography and intraoperative cholangiography are complementary, as the combination of both methods maximizes the intraoperative detection of choledocholithiasis.

L’arret du tabac est recommande en preoperatoire de la chirurgie de l’obesite car cela augmente les complications et cela est associe a une augmentation risque de mortalite venant juste apres le poids. Nous voulions savoir si la chirurgie qui diminue l’addiction a la nourriture diminuait aussi l’addiction au tabac et modifiait les resultats ponderaux de la chirurgie. Cent quarante-six sur 798 patients operes entre avril 2010 et aout 2015 ont repondu a un questionnaire sur leurs habitudes de tabagisme avec les questions suivantes : etiez-vous fumeur avant l’intervention ? Combien ? Etes-vous fumeur actuellement ? Combien ? L’âge moyen des patients etait de 45,41 ans (extremes 22–62 ans), avec 83,6 % de femmes et un IMC moyen de 44 kg/m2 (extremes 33–76). Dix-huit etaient fumeurs (33 % d’hommes) avant l’intervention (12,3 %). Les fumeurs etaient 3 ans plus jeunes, pesaient 6 kg de plus avant l’intervention, et avaient un IMC final identique apres 2,18 ans de suivi (non significatif). Le tabagisme a ete modifie chez 8 sujets avec deux nouveaux fumeurs, 2 ont arrete de fumer (1 a opte pour la cigarette electronique) et 3 ont diminue leur consommation. Les fumeurs ont perdu 1 point d’IMC en plus, sans que la perte de poids soit significativement differente (test de t, bilateral, p = 0,643). Ainsi, les fumeurs n’ont pas des resultats de perte de poids inferieurs. La chirurgie ne semble pas aider sur l’arret du tabac meme si en preoperatoire tous les patients etaient informes de la necessite d’arreter de fumer pour eviter des complications.

Le bypass gastrique (BP) est considere comme la chirurgie de reference avec d’excellents resultats ponderaux a long terme et de remarquables ameliorations des comorbidites associees. Nous voulions demontrer que la gastrectomie longitudinale (SG) est non inferieure au BP pour la perte de poids et les complications avec un suivi de 36 mois. Cette etude etait initialement prospective randomisee, controlee, multicentrique, avec une analyse de donnees en intention de traiter. Apres les 40 premiers patients, nous avons ete contraints de passer a une etude non randomisee prospective en soins courants. L’etude a teste deux hypotheses : une hypothese sur la difference de frequence de la morbi-mortalite et la non-inferiorite sur la reduction de l’exces de poids > 50 %. Deux cent soixante-dix-sept patients ont ete inclus entre fevrier 2008 et mars 2012 (91 BP vs. 186 SG). L’âge moyen etait de 41,1 ans, avec 85,9 % de femmes et un IMC moyen de 45,25 kg/m2. La perte d’un exces poids > 50 % a 36 mois etait non inferieure : 79,12 % et 79,46 % pour le BP et la SG respectivement. A 36 mois, il y avait une difference significative pour le critere composite de morbi-mortalite 15,4 % (BP) vs. 5,9 % (SG) (p = 0,0098). L’amelioration des comorbidites etait similaire dans les deux groupes. Il s’agit de la premiere etude de cette taille prospective francaise demontrant que la SG est non inferieure dans la perte de poids et moins risquee que le BP. Cela conforte le choix des patients, des chirurgiens et des autorites administratives pour preferer la SG.