Long-term results of adjustable gastric banding in a cohort of 186 super-obese patients with a BMI≥ 50 kg/m2

BACKGROUND

There are conflicting results concerning the bariatric effectiveness of adjustable gastric banding in super-obese patients with a Body Mass Index (BMI) more or equal to 50 kg/m(2).

METHOD

A cohort of 186 patients with a BMI greater or equal to 50 kg/m(2) who underwent adjustable gastric banding (AGB) at the Bichat-Claude-Bernard University Hospital (Paris, France) were prospectively entered into a database. The following data were recorded: BMI, percentage of BMI loss, percentage of excess weight lost (%EWL), complications, and surgical re-interventions. Loss of greater than 50% of excess weight was considered a success (primary endpoint). A %EWL of less than 25% after one year, or the removal of the gastric band was considered a failure.

RESULTS

Thirty-five men (18.8%) and 151 women (81.2%), with a mean age of 38.9 years (range: 16-65) underwent AGB between September 1995 and December 2007. The mean BMI was 55.06 kg/m(2) (range: 50-74.4). Mean follow-up was 112.5 months with a minimum of 28 months and a maximum of 172 months. The follow-up rate was maintained at 89% at ten years. The technique of AGB was by "peri-gastric dissection" in the first 115 patients (61.82%) and by "pars flaccida dissection" in 71 patients (38.17%). The gastric band was removed in 87 of 186 patients (46.8%); band ablation was due to a complication of the gastric band in 62 of these cases (33.3%), to failure of weight loss in 23 cases (12.4%), and to patient request in two cases (1%). The major complications requiring re-operation were: chronic dilatation of the proximal gastric pouch (27 patients - 14.5%), acute dilatation (21 patients - 11.3%), intragastric migration of the prosthesis (six patients - 3.2%), reflux esophagitis (six patients - 3.2%), infection of the gastric band (one patient - 0.5%), and Barrett's esophagus (one patient - 0.5%). No statistically significant difference was found between the two operative techniques with regard to the possibility of preserving the gastric band for ten years. For patients who underwent band removal, no further follow-up analysis of patient data after band ablation was performed. The results were best at two years after AGB with a median BMI of 42.72 kg/m(2), a band removal rate of 8.6% (16 of 186 patients), and a failure rate of 16.4% (28 of 170 patients) of those patients who still had their band in place. However, at 10 years, the picture was completely reversed with a band removal rate of 52.2% (47 of 90 patients), a failure rate of 22% (seven of 33 patients) of those who still had their band in place, and a median BMI of 43.43 kg/m(2).

CONCLUSION

Laparoscopic gastroplasty using the adjustable gastric band appeared to be a promising intervention for super-obese patients when the results at two years were analyzed - fairly simple to perform, with perioperative morbidity and mortality near zero. However, these results do not persist in the long-term for super-obese patients. At ten years, only 11% of patients (nine of 80) have successful bariatric results (%EWL>50%) and we were forced to remove the gastric band in 52.2% of patients (47 of 90) because of complications, regardless of the initial operative technique used. Given these results, AGB gastroplasty is not a recommended method for super-obese patients and we believe that a BMI greater or equal to 50 kg/m(2) is a contra-indication for this procedure.

[54-year-old male with hepatic cirrhosis and therapy-associated torsade de pointes tachycardia]

We present a case of a patient with newly diagnosed cirrhosis and kidney failure who underwent cardiopulmonary resuscitation twice after treatment with terlipressin. After the second application a QT interval prolongation and torsade de pointes were documented. Since other causes were excluded, we interpret both events as terlipressin-induced ventricular arrhythmia. Therefore, it seems important to consider this rare but potentially lethal side effect when administering this drug to patients.

Local estimation of lattice constants in HRTEM images

A model-based approach to estimate lattice constants from an atomically resolved HRTEM image is presented. The approach only utilizes the inherent periodicity of these images and does not require a centrosymmetric structure of the specimen. This allows the evaluation of, for instance, wurtzite-based materials like InGaN/GaN heterostructures. The lattice constants are determined within precisions below 3 pm from areas only a few unit cells large. This makes this method suitable for further strain/compositional analysis. Furthermore, the impact of the approximations of the true detector's covariance matrices on the assessment of the model-based approach is investigated, and insights into the quality of these noise models of the detector are gained.

[Intratumoral Onyx embolisation in the management of juvenile nasopharyngeal angiofibroma]

Preoperative embolization for the treatment of juvenile nasopharyngeal angiofibroma was successfully accomplished with Onyx by intratumoral puncture for the first time. Extratumoral migration of Onyx particles was not observed, precluding the necessity to inflate the shield balloon. Postinterventional angiography showed complete occlusion of all supporting blood vessels. Transnasal surgery on the following day achieved complete resection of the angiofibroma without complications. Direct intratumoral embolization of juvenile nasopharyngeal angiofibromas appears to be a safe and effective preoperative method without complications. It could represent a new strategy for the treatment of JNA, as is already the case with other highly vascularized head and neck tumors. Moreover, it increases the likelihood of achieving complete resection.

[Recurrent ovarian fibromas in condition of Gorlin syndrome]

Gorlin syndrome also known as basal cell nevus syndrome is a rare autosomal dominant condition with variable expression. This syndrome is characterized by many anomalies of development and by the propensity of developing multiple neoplasms. We report a case of a 20-years-old French patient who has relapsing ovarian bilateral fibromas in condition of Gorlin syndrome. These fibromas are present in 25 % of Gorlin syndrome cases, which often are bilateral. The economic resection of these fibromas is recommended in spite of the risk of recurrence to preserve the fertility.

Assessment of genotoxicity of Lidocaine, Prilonest and Septanest in the Drosophila wing-spot test

The scope of this study was to characterize the likely interaction Lidocaine, Prilonest and Septanest have with DNA, with a view to quantitatively and qualitatively establishing mutagenic, clastogenic, and/or recombinagenic activity of those compounds. The wing somatic mutation and recombination test in Drosophila melanogaster, which detects simultaneously point and chromosomal mutations as well as recombination induced by the activity of genotoxins of direct and indirect action, was used. Each of the anesthetics was tested at different concentrations, administered orally for 48 h to 3rd-stage larvae, in two independent experiments, with concurrent negative controls. The results obtained revealed that only Prilonest exhibits genotoxic activity in somatic cells, being able to induce exclusively homologous recombination. Additionally, it was possible to conclude that the genotoxic effect attributed to Prilonest is not related to metabolites produced via the P450-type enzymes. However, both Lidocaine and Septanest are unable to induce either events related to gene and chromosomal mutation, or reciprocal recombination.

Dextran sulfate facilitates anti-CD4 mAb-induced long-term rat cardiac allograft survival after prolonged cold ischemia

Ischemia/reperfusion injury leads to activation of graft endothelial cells (EC), boosting antigraft immunity and impeding tolerance induction. We hypothesized that the complement inhibitor and EC-protectant dextran sulfate (DXS, MW 5000) facilitates long-term graft survival induced by non-depleting anti-CD4 mAb (RIB 5/2). Hearts from DA donor rats were heterotopically transplanted into Lewis recipients treated with RIB 5/2 (20 mg/kg, days-1,0,1,2,3; i.p.) with or without DXS (grafts perfused with 25 mg, recipients treated i.v. with 25 mg/kg on days 1,3 and 12.5 mg/kg on days 5,7,9,11,13,15). Cold graft ischemia time was 20 min or 12 h. Median survival time (MST) was comparable between RIB 5/2 and RIB 5/2+DXS-treated recipients in the 20-min group with >175-day graft survival. In the 12-h group RIB 5/2 only led to chronic rejection (MST = 49.5 days) with elevated alloantibody response, whereas RIB 5/2+DXS induced long-term survival (MST >100 days, p < 0.05) with upregulation of genes related to transplantation tolerance. Analysis of the 12-h group treated with RIB 5/2+DXS at 1-day posttransplantation revealed reduced EC activation, complement deposition and inflammatory cell infiltration. In summary, DXS attenuates I/R-induced acute graft injury and facilitates long-term survival in this clinically relevant transplant model.

Genes and biological processes controlled by the Drosophila FOXA orthologue Fork head

The larval salivary glands of Drosophila express the FOXA transcription factor Fork head (Fkh) before, but not after, puparium formation. Forced expression of Fkh in late prepupae prevents the programmed destruction of the tissue, which normally occurs in the early pupa. Using Affymetrix GeneChips, we analysed changes in gene expression brought about by Fkh when expressed shortly before the normal time of salivary gland death. Genes identified as responsive to Fkh include not only cell death genes, but also genes involved in autophagy, phospholipid metabolism and hormone-controlled signalling pathways. In addition, Fkh changed the expression of genes involved in glucose and fatty acid metabolism that are known to be target genes of the FOXAs in vertebrates. Premature loss of fkh induced by RNAi and gain of Fkh by ectopic expression at earlier times of development confirmed that genes identified in the microarray study are under normal developmental control by Fkh. These genes include Eip63F-1, which is expressed in both salivary glands and Malpighian tubules, suggesting that Fkh controls common aspects of the secretory function of the two organs. Eip63F-1 is one of many genes controlled by the steroid hormone 20-hydroxyecdysone that appear to be co-regulated by Fkh.