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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.

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.

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.

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.