Pulmonary hemodaynamic in obesity

Background

Higher prevalence of pulmonary hypertension exist in obesity subjects. Little known about pulmonary hemodynamics during exercise in obesity population.

Purpose

To assess and compare the response of pulmonary vascular resistance during exercise in obese subjects vs healthy controls.

Methods

Seventeen obesity subjects (gender: 25%men, age: 44±11 years, height: 1.7±0.1 m, weight: 111±17 kilogram, BMI: 38±4 kg/m2) were compared to twenty gender-, age-, height- and race-matched healthy control subjects (age: 46±12 years, height: 1.7±0.1 m, weight: 64±11 kilogram, BMI: 22±2 kg/m2). All subjects underwent an incremental exercise stress echocardiography with measurements of pulmonary artery pressure (PAP), cardiac output (CO), cardiac index (CI) and tricuspid annular plane systolic excursion (TAPSE) at rest and at increasing exercise intensities. Total pulmonary vascular resistance index (PVRi) was calculated as mean PAP/CI and right ventricular-arterial coupling as TAPSE/systolic PAP.

Results

The results are described in the table 1. Pulmonary hemodynamic was not different at rest between two groups, but lower at maximal exercise in obesity subjects. In obesity subjects, identical exercise level was associated with a higher mean PAP and PVRi, and a lower TAPSE/systolic PAP ratio.

Conclusion

While pulmonary hemodynamic seems preserved at rest in obesity patients, pulmonary vascular resistance is increased and right ventricular coupling is decreased, particularly at exercise.

Funding Acknowledgement

Type of funding source: None

Assessment of the optimal timing for early laparoscopic cholecystectomy in acute cholecystitis: a prospective study of the Club Coelio

Background: The optimal timing for cholecystectomy in patients with acute cholecystitis remains controversial. The aim of this study is to assess prospectively the impact of the duration of symptoms on outcomes in early laparoscopic cholecystectomy (ELC) for acute cholecystitis. Methods: The series consisted of 276 consecutive patients who underwent ELC for acute cholecystitis in 2016. The patients were divided into three groups according to the timing of surgery: within the first 3 days (group 1), between 4 and 7 days (group 2) and beyond 7 days (group 3) from the onset of symptoms. Results: The percentage of surgical procedure rated as difficult was respectively: 12% in G1, 18% in G2 and 38% in G3 (p < .001). Accordingly, we observed an increased mean operative time within groups but no significant difference in the conversion rate. We noted a different overall postoperative complication rate within groups, respectively: 9% in G1, 14% in G2 and 24% in G3 (p < .04). The median hospital stay was also different within groups, respectively: 3 in G1, 4 in G2 and 6 days in G3 (p < .001). On univariate analysis, age ≥60, male gender, ASA 3, WBC ≥13.000/µL, CRP ≥100 mg/l and delay between onset of symptoms and surgery were factors statistically associated with increased morbidity rate. On multivariate analysis, the delay was the only independent predictive factor of postoperative morbidity (OR: 1,08, 95% CI: 1.01-1.61, p < .031). Conclusion: Our study confirms that it is ideal to perform ELC within 3 days of symptoms onset and reasonable between 4 to 7 days. We do not recommend performing ELC beyond 7 days because of more difficult procedure and significantly increased risk of post-operative complications.

Risk factors of perioperative morbimortality after laparoscopic sleeve gastrectomy: a club coelio multicenter study

OBJECTIVES

Postoperative complications after Laparoscopic sleeve gastrectomy (LSG) can dramatically compromise patient's outcome. The aim of this study is to analyze the per- and postoperative short-term outcomes after LSG and to assess predictive risk factors of complications.

METHODS

The study group consisted of 790 patients (610 women and 180 men) who underwent LSG In 2014. All interventions were performed by 18 experienced surgeons members of the Club Coelio. Data about preoperative work-up, surgical techniques, 30-days postoperative morbidity and mortality were collected. Endpoints were perioperative morbidity and mortality and assessment of potential risk factors for complications.

RESULTS

Mean age and body mass index were respectively 39 years and 41.5kg/m². Ninety-one patients (11.5%) had previous bariatric surgery. Morbidity rate was 4.7% (37/790) including 16 leaks (2.0%) and 9 bleedings (1.1%) and no deaths. Risk factors for leak were: previous adjustable banding (p = .0051), with no difference between removal of the banding and LSG in 1 or 2 steps, and type of endostapler (p = .0129).

CONCLUSIONS

Leakage after Sleeve was rare but still observed even in experienced hands. The leak rate is particularly high when LSG is performed after adjustable gastric banding removal.

Laparoscopy-assisted transjejunal ERCP in a patient with roux-en-Y gastric bypass

In the case of Roux-en-Y gastric bypass with a long afferent limb, the need to carry out an ERCP still represents a technical challenge. In this article we describe the case of a 50-year-old male admitted to the ER for abdominal pain in the right upper quadrant, in the context of prior Roux-en-Y gastric bypass (4 years ago), with uncomplicated gallbladder stones discovered 3 months ago. The patient presented recurrent abdominal pain for 3 months but in the last few days the pain became continuous. The blood test revealed elevation of hepatic enzymes and bilirubin levels. The US findings were uncomplicated gallbladder lithiasis with no signs of lithiasic migration in the common bile duct, despite strong clinical suspicion and positive MRI 3 weeks before. We decided therefore to perform a laparoscopic cholecystectomy with perioperative cholangiography and a laparoscopy-assisted transjejunal ERCP through a jejunostomy 80 cm distal to the ligament of Treitz, allowed us to successfully carry out sphincterotomy and extraction of a 10mm lithiasis from the common bile duct.

Gastric Bypass for Morbid Obesity in a Patient with Situs Inversus Totalis

The aim of this case report is to outline the challenge and the feasibility of laparoscopic gastric bypass in a patient with situs inversus totalis. Situs inversus totalis does not seem to be a contraindication for laparoscopic surgery.

Gastric bypass for morbid obesity in a patient with situs inversus totalis

The aim of this case report is to outline the challenge and the feasibility of laparoscopic gastric bypass in a patient with situs inversus totalis. Situs inversus totalis does not seem to be a contraindication for laparoscopic surgery.

Previous bariatric surgery increases postoperative morbidity after sleeve gastrectomy for morbid obesity

OBJECTIVES

Sleeve gastrectomy (SG) has been used as the first step of a staged malabsorptive procedure for high-risk patients. More recently SG was proposed as an stand alone procedure in the treatment of morbidly obese patients. The aim of this study is to analyze perioperative outcome of morbid obese patients after SG.

METHODS

301 patients, 201 women and 100 men, undergoing SG were retrospectively analyzed. SG was performed by 17 surgeons all member of the Club Coelio. The mean BMI was 44.7kg/m2 (27.4-70.3 kg/m2). 34 patients (11.3%) of our series had SG as revisional surgery. These revisional procedures consisted of 32 conversions from gastric banding, 1 conversion from vertical gastroplasty (VBG) and 1 from transoral endoscopic gastroplasty. Among the 32 patients that had revisional SG after a gastric banding, 13 bands were removed at least 3 months before the revisional SG and 19 bands were removed during the SG procedure. Endpoints were perioperative morbidity and mortality and potential risk factors for complications, mainly per or postoperative bleeding or leakage.

RESULTS

Overall mortality was 0% and morbidity was 10.3%. Perioperative bleeding occurred in 10 patients (3.3%), leakage in 12 patients (4%) patients and stenosis in 3 patients (1%). The risk of leakage was significantly higher after revisional bariatric surgery and in case of gastric perforation during surgery (p = 0.0001). Previous gastric banding is also associated with a higher risk of postoperative bleeding (p = 0.0006).

CONCLUSIONS

SG can be safely performed but patients and surgeons must be aware of a higher risk of postoperative complications when SG is proposed as a revisional surgery.

Contribution of CXCR4 and SMAD4 in predicting disease progression pattern and benefit from adjuvant chemotherapy in resected pancreatic adenocarcinoma

BACKGROUND

Prognosis of patients with pancreatic adenocarcinoma is poor. Many prognostic biomarkers have been tested, but most studies included heterogeneous patients. We aimed to investigate the prognostic and/or predictive values of four relevant biomarkers in a multicentric cohort of patients.

PATIENTS AND METHODS

A total of 471 patients who had resected pancreatic adenocarcinoma were included. Using tissue microarray, we assessed the relationship of biomarker expressions with the overall survival: Smad4, type II TGF-β receptor, CXCR4, and LKB1.

RESULTS

High CXCR4 expression was found to be the only independent negative prognostic biomarker [hazard ratio (HR) = 1.74; P < 0.0001]. In addition, it was significantly associated with a distant relapse pattern (HR = 2.19; P < 0.0001) and was the strongest prognostic factor compared with clinicopathological factors. In patients who did not received adjuvant treatment, there was a trend toward decrease in the overall survival for negative Smad4 expression. Loss of Smad4 expression was not correlated with recurrence pattern but was shown to be predictive for adjuvant chemotherapy (CT) benefit (HR = 0.59; P = 0.002).

CONCLUSIONS

CXCR4 is a strong independent prognostic biomarker associated with distant metastatic recurrence and appears as an attractive target to be evaluated in pancreatic adenocarcinoma. Negative SMAD4 expression should be considered as a potential predictor of adjuvant CT benefit.

[Gastric adenocarcinoma following "silastic vertical ring gastroplasty": case report]

OBJECTIVES

Bariatric surgery is considered as the most effective therapy for morbid obesity. But, each procedure carries both short-and long-term complications. And, it remains unclear if the late occurrence of gastric adenocarcinoma could be linked to bariatric surgery. We described a case of a female who developed a gastric adenocarcinoma after a silastic ring vertical gastroplasty (SRVG).

METHODS

A 54-year-old female presented with postprandial vomiting, poor appetite, dysphagia and weight loss 10 year after a SRVG. A gastroscopy with biopsy disclosed a juxta-pyloric adenocarcinoma. No distant metastasis was found. After 3 cycles of neoadjuvant chemotherapy, a subtotal gastrectomy with Roux-en-Y anastomosis was performed.

RESULTS

After the surgery, a minor anastomotic leak was treated conservatively and a parietal abscess was drained. The pathological studies demonstrated a T2bN1 adenocarcinoma with negative margins. Adjuvant chemotherapy was administered. At the last work up, the patient is disease-free.

CONCLUSION

The association between a gastric adenocarcinoma and a bariatric procedure such as a SRVG is difficult to assess without a case-control or a cross-sectional study. Nevertheless, when new upper digestive tract complaints occur in any patient with an otherwise unremarkable bariatric surgery follow-up, the diagnosis of gastric cancer should be bear in mind.

Transoral gastroplasty is safe, feasible, and induces significant weight loss in morbidly obese patients: results of the second human pilot study

BACKGROUND AND STUDY AIMS

Bariatric surgical treatments have been proven to induce long-term weight loss in morbidly obese patients, but complications are relatively frequent. We recently reported a first human multicenter trial assessing the safety, feasibility, and weight loss results of the Transoral Gastroplasty (TOGA) system (Satiety Inc., Palo Alto, CA) at 6 months. Here we report the 6-month results of the second phase of the pilot trial with the TOGA system, with technical improvements to the device.

PATIENTS AND METHODS

Patients met established criteria for bariatric surgery. The TOGA system, a set of transoral endoscopically guided staplers, was used to create a stapled restrictive pouch along the lesser curvature of the stomach. Follow-up was at 1 week and at 1, 3, and 6 months. At 3 months, re-treatment consisting in additional distal restrictions was allowed if necessary.

RESULTS

Data were available for 11 patients in our center (7 female, mean age 44.2 years, mean body mass index 41.6). The procedure was completed safely in all patients. There were no serious adverse events. Mean excess weight loss was 19.2 %, 33.7 %, and 46.0 % at 1, 3, and 6 months, respectively. Average body mass index decreased from 41.6 before treatment to 33.1 at 6 months. Absolute mean weight loss was 9.9 kg, 17.5 kg, and 24.0 kg at 1, 3, and 6 months, respectively. A dramatic improvement in quality-of-life measures was observed in all patients.

CONCLUSIONS

This second pilot trial confirmed the feasibility and safety of transoral gastroplasty. The early results and technical improvements reported in the present study are encouraging in terms of safety, early weight loss, and quality of life, and clearly allowed multicenter trials, which are planned to start soon.

Nissen versus Toupet fundoplication: results of a randomized and multicenter trial

BACKGROUND

Laparoscopic Toupet fundoplication (TF) is reported to be as effective as Nissen (NF), but to be associated with fewer unfavorable postoperative side-effects. This study evaluates the one- and three-year clinical outcome of 140 randomized patients after a laparoscopic NF or TF.

PATIENTS AND METHODS

Inclusion criteria included patients over 16 years old with complications of gastro-oesophageal reflux disease (GORD) and persistence or recurrence of symptoms after three months of treatment. Subjects with a previous history of gastric surgery or repeated fundoplication, brachy-oesophagus or severe abnormal manometry results were excluded. Seventy-seven NF and 63 TF were performed. The severity of symptoms was assessed before and after the procedure.

RESULTS

One hundred and twenty-one of the 140 patients after one year, and 118 after three years, were evaluated and no statistically significant clinical difference was observed. The level of satisfaction concerning the outcome of the operation remained high after one or three years regardless of the type of fundoplication performed.

CONCLUSIONS

Functional complications after NF are not avoided with TF.

Safety, feasibility and weight loss after transoral gastroplasty: First human multicenter study

OBJECTIVE

To evaluate the safety and feasibility in human subjects of a new transoral restrictive procedure for the treatment of obesity.

METHODS

The protocol was approved by the institutional review boards (IRBs) of both centers involved, and all patients gave informed consent. Patients met established inclusion criteria for bariatric surgery. The TOGa system (Satiety Inc., Palo Alto, CA), a set of transoral endoscopically guided staplers, was used to create a stapled restrictive pouch along the lesser curve of the stomach. Patients were hospitalized overnight for observation and underwent barium upper gastrointestinal (UGI) the next morning. Post procedure, all patients were placed on a liquid diet for 1 month and asked to begin an exercise program. Follow-up was carried out at 1 week and 1, 3, 4, 5, and 6 months.

RESULTS

Twenty one patients were enrolled [17 female, age 43.7 (22-57) years, BMI 43.3 (35-53) kg/m(2)]. Device introduction was completed safely in all patients. There were no serious adverse events (AEs). The most commonly reported procedure or device related adverse events were vomiting, pain, nausea, and transient dysphagia. At 6 month endoscopy, all patients had persistent full or partial stapled sleeves. Gaps in the staple line were evident in 13 patients. Patients lost an average 17.6 pounds at 1 month, 24.5 pounds at three months, and 26.5 pounds at 6 months post-treatment [excess weight loss (EWL) of 16.2%, 22.6%, and 24.4%, respectively].

CONCLUSIONS

There is great interest in new procedures for morbid obesity that could offer lower morbidity than current options. Early experience with the TOGa procedure indicates that this transoral approach may be safe and feasible. Further experience with the device and technique should improve anatomic and functional outcomes in the future. Additional studies are underway.

[Bariatric surgery: which patient for which type of surgery?]

Bariatric surgery remains the only durable option for weight loss in the morbidly obese patient. The aim of this article is to present the different types of surgical procedures. This multidisciplinary approach try to define which type of surgery would be the more indicated for which patient.

Results of silastic ring vertical gastroplasty more than 6 years after surgery: analysis of a cohort of 214 patients

BACKGROUND

Among the different techniques of surgical treatment for morbid obesity, silastic ring vertical gastroplasty (SRVG) is an alternative, effective and easily reproducible technique. The aim of this study is to evaluate a cohort of patients >6 years after SRVG for morbid obesity.

METHODS

From 1991 to 1996, 273 consecutive patients were eligible for SRVG. The evaluation criteria included weight loss, evolution of co-morbidities, long-term morbidities, satisfaction of patients and quality of life.

RESULTS

Among these 273 patients, 1 patient died in the postoperative period (0.4%). Postoperative morbidities occured in 27 patients (10%). The long-term follow-up involved 213 patients (78%). Late postoperative complications consisted of outlet stoma stenosis (14%), staple-line dehiscence (5.6%) and incisional hernia (8.5%). 23 patients (10%) needed a re-do operation. Co-morbidities drastically improved. BMI fell from 45.3 to 30.7. Failure of SRVG was statistically associated with male gender and super-obese patients. 69% of the patients were satisfied, and 73% would recommend this operation.

CONCLUSION

SRVG is very effective in a selected group of morbidly obese patients.

Laparoscopic Nissen fundoplication after failure of Enteryx injection into the lower esophageal sphincter

BACKGROUND

We investigated the feasibility, safety, and efficacy of laparoscopic antireflux surgery (LARS) after failure of Enteryx injection in the lower esophageal sphincter for the treatment of gastroesophageal reflux disease (GERD).

METHODS

Four patients underwent LARS after failure of Enteryx injection. Particular care was taken during the procedure to identify unusual material or fibrosis.

RESULTS

All patients underwent LARS successfully. In three patients, tight adhesions with fibrous tissues and black foreign material were observed around the esophagus. No complications occurred during the procedures. The postoperative period was uneventful and functional results were excellent.

CONCLUSION

LARS following Enteryx injection is feasible. Careful dissection is mandatory to avoid operative complications. Both techniques may be considered as options for treating GERD.

Right hepatic artery pseudoaneurysm and cystic duct leak after laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) seems to be associated with an increased risk of biliary or vascular injuries. Hepatic artery pseudoaneurysms (HAP) are rare complications of LC. HAP can occur in the early or late postoperative period. Patients with HAP present with abdominal pain, hemobilia, and liver function test (LFT) alterations. We report the case of a patient who was affected with a cystic duct stump leak associated with a right HAP and was treated by endoscopic biliary drainage and angiographic coil embolization.

Delayed gastric emptying after pancreatoduodenectomy

With pylorus-preserving pancreatoduodenectomy (PPPD) the goal is to reduce long-term morbidities such as gastric dumping, marginal ulceration or bile-reflux gastritis. Compared with te classical Whipple procedure, PPPD is affected by an equal postoperative morbidity but is known to induce delayed gastric emptying (DGE). It is difficult to evaluate the true incidence of DGE after PPPD (from 5 to 50% according to the literature). Early and low doses of erythromycin in the postoperative period could prevent the onset of DGE and the administration of cisapride 15 mg/day improves gastric emptying up to 6 months after PPPD.

[The surgical gastroenterology department]

The Department of Digestive Surgery was born in 1977. It is a part of the medical surgical unit of gastroenterology and hepatopancreatology. The various developed sectors concern hepatic surgery and liver transplantation (treatment of hepatic tumors and cirrhosis), pancreatic surgery and surgery of the biliary tract (treatment of benign and malignant pancreatic tumors, tumor of the biliary tract, chronic pancreatitis and biliary stones), surgery of morbid obesity (gastroplasty or gastric by-pass), surgery of the upper digestive tract (benign and malignant tumors of the oesophagus or the stomach, treatment of gastroesophageal reflux), surgery of the abdominal wall, colorectal surgery and surgery of the inflammatory bowel diseases (colorectal cancer, familial polyposis, Crohn's disease, ulcerative colitis), proctologic surgery and surgery of anorectal functional disorders, neonatal and paediatric surgery.

An improved radioimmunoassay for measurement of pepsinogen in porcine blood samples

The study was conducted to develop a sensitive and specific radioimmunoassay (RIA) for the measurement of pepsinogen in porcine serum, and to use this test for the determination of pepsinogen concentrations in serum samples from fetuses and pigs of different ages. Compared to a previously described RIA, major improvements were made concerning the use of specific polyclonal antibodies and the use of an appropriate buffer. The assay was able to detect pepsinogen concentrations of >/=0.2 ng/mL. The recovery of pepsinogen was close to 95%. The intra-assay coefficients of variations ranged between 3.9 and 7.5% whereas the interassay ranged between 8.8 and 11.9%. These percentages correspond to a satisfactory accuracy and reproducibility of the assay. No cross-reactions were observed with the main commercially available products of the aspartic proteases family except porcine pepsin cross-reacted over 62.5 microg/mL. Pepsinogen concentrations increased steadily with increasing age of the fetuses and the pigs (P<0.05). Pepsinogen concentrations (+/-SE) in fetuses of 90-100 (n=24) and 100-110 days of pregnancy (n=36) were 0.5+/-0.1 and 5.3+/-1.3 ng/mL, respectively. In pigs of 21, 98, and 213 days of age, the pepsinogen concentrations were 290.6+/-10.8, 343.1+/-17.9 and 383.5+/-15.3 ng/mL, respectively. The results demonstrate that RIA is accurate and can be used easily to assess pepsinogen concentrations in pig sera. The test may constitute a valuable tool in epidemiological surveys and in studies related to gastric diseases in pigs.

Metastatic carcinoma of the gallbladder after a renal cell carcinoma

The gallbladder is rarely the site of distant metastases and in most cases malignant melanoma is the primary tumor. We report a case of a 64-year-old man with a gallbladder metastasis secondary to a renal cell carcinoma. Renal cell carcinoma has a tendency toward metastatic disease, the most notable features of this tumor being its unusual pattern of metastatic disease. Pre-operative imaging studies are often futile in the differentiation between primary and secondary tumors of the gallbladder. Since primary tumors of the gallbladder often coexist with gallstones, a polypoid lesion in an acalculous gallbladder is more consistent with metastasis than a primary tumour. If feasible, surgical resection of the gallbladder is mandatory because it could guarantee better chances of survival for patients with metastatic renal carcinoma.

Wilkie's syndrome

A superior mesenteric artery syndrome (SMAS) was diagnosed in two young women with, respectively, a 2- and 1-year history of postprandial vomiting and epigastric pain. The patients underwent a laparoscopic duodenojejunal bypass, and resumed a normal diet on the fifth postoperative day. The patients are still symptom-free with patent anastomosis on gastrointestinal radiographic control at 24 and 6 months, respectively, following their operation. Herein we also describe the varying clinical presentation of this rare syndrome, as well as treatment options. We conclude that laparoscopic duodenojejunostomy offers a new therapeutic approach to SMAS. It is reliable and safe; the operating time is acceptable; and diet recovery and hospital stay are both short. However, these preliminary results still need to be confirmed by further observations.

IGF -I plasma concentrations in non-treated horses and horses administered with methionyl equine somatotropin

Insulin-like growth factor-I (IGF -I) is likely to be an indicator of somatotropin (ST) administration in the horse. To investigate the different ways ST administration may be detected, the following aspects of IGF -I concentrations in plasma were studied: (i) the daily variation; (ii) variation following a treadmill test; (iii) concentrations at rest and after exercise; and (iv) concentrations in plasma from two young horses and two adults treated with methionyl equine somatotropin (e ST). In the population of horses at rest, IGF -I mean concentration (SEM) was 261 (104) ng ml(-1). In post race samples, IGF -I mean concentration was 187 (100) ng ml(-1). All of these data indicate that exercise does not modify IGF -I concentration in plasma. The magnitude of the increase in IGF -I following administration of e ST differed according to the age of the horses. The critical value of 700 ng ml(-1)was exceeded for 1 day in adult horses and for at least 11 days in young horses. These results show that IGF -I has potential as an indirect marker of ST administration in horses.

Domino hepatic transplantation using the liver from a patient with primary hyperoxaluria

BACKGROUND

We report a case of domino liver transplantation using the liver harvested from a patient who underwent a combined liver and kidney transplantation for primary hyperoxaluria (PH).

METHOD

A cadaveric liver transplantation was performed in a 19-year-old man with PH. In a second step, the PH liver harvested from the first patient was transplanted in a 69-year-old man with hepatitis C-related cirrhosis, not a candidate for a classic liver graft owing to multifocal hepatocellular carcinoma.

RESULTS

At 8 months after transplantation, the domino recipient has normal hepatic function and no signs of tumoral recurrence, but he progressively developed hyperoxalemia, hyperoxaluria, and renal insufficiency.

CONCLUSION

Regarding the favorable postoperative clinical evolution, domino liver transplantations using livers from PH patients may represent a new opportunity for marginal candidates for liver transplantation. However, the progressive renal insufficiency expected in such domino recipients should limit this procedure to selected cases.

What did the laparoscopic Nissen approach of the gastro-oesophageal reflux really change for the patients 8 years later?

BACKGROUND

Nissen fundoplication (NF) is recognized as the surgical treatment of the gastro-oesophageal reflux disease (GERD). NF can be achieved either by open surgery or by laparoscopic approach.

METHODS

From 1987 to 1997, 210 patients were treated for GERD by NF: 61 by open and 149 by laparoscopic approach. All the patients were followed more than 1 year and were scored by clinical assessment (Visick scale adaptation). In case of Visick score > 1, GI-endoscopy, X-ray series or 24-hour pH-study complete the evaluation.

RESULTS

The operative time was comparable between both groups. The postoperative recovery was statistically faster in the laparoscopic group (p = 0.0001). The mean time of follow-up was 6 years after open NF and 4 years after laparoscopic NF. After open NF or laparoscopic NF, 72% and 67% of the patients are respectively scored Visick 1, 13% and 21%--Visick 2, 6.8% and 6%--Visick 3 and 8.2% and 6%--Visick 4 (NS). Patients with recurrence of GERD were scored Visick 4, so failure of the surgical treatment is observed in 5 patients after open NF and 9 patients after laparoscopic NF. The occurrence of incisional hernia was significantly higher in the open group (p = 0.0001).

CONCLUSION

NF remains a safe procedure for surgical treatment of GERD and can be achieved by laparoscopic approach with comparable results to those by open laparotomy. In our experience, the advantages of the laparoscopic approach is a faster postoperative recovery and a lower risk of incisional hernia.

Helical CT signs in the diagnosis of intestinal ischemia in small-bowel obstruction

OBJECTIVE

The purpose of our study was to determine prospectively the value of helical CT and of various signs of ischemia in the context of acute bowel obstruction.

SUBJECTS AND METHODS

All patients seen over a 3-year period with a CT diagnosis of small-bowel obstruction were included. There were 144 examinations in 142 patients. Images were interpreted prospectively with consensus by a fellow and an experienced gastrointestinal radiologist. Attention was focused on the presence of the following signs of strangulation and ischemia: reduced enhancement of the small-bowel wall, mural thickening, mesenteric fluid, congestion of small mesenteric veins, and ascites. A diagnosis of ischemia was made if enhancement of the bowel wall was reduced or if at least two of the other signs were found. Results were correlated with surgical findings in 73 cases and clinical follow-up in 71 cases.

RESULTS

A diagnosis of ischemia was made at surgery in 24 patients. CT diagnosis was correct in 23 patients (96% sensitivity). There were nine false-positive diagnoses (93% specificity). The negative predictive value of CT was 99%. Reduced enhancement of the bowel wall had a sensitivity of 48% and specificity of 100%, mural thickening had a sensitivity of 38% and specificity of 78%, mesenteric fluid had a sensitivity of 88% and specificity of 90%, congestion of mesenteric veins had a sensitivity of 58% and specificity of 79%, and ascites had a sensitivity of 75% and specificity of 76%.

CONCLUSION

Helical CT is a highly sensitive method to diagnose or rule out intestinal ischemia in the context of acute small-bowel obstruction.

A novel messenger ribonucleic acid homologous to human MAGE-D is strongly expressed in rat Sertoli cells and weakly in Leydig cells and is regulated by follitropin, lutropin, and prolactin

We have cloned a novel complementary DNA whose expression was decreased in rat Sertoli cell cultures after treatment with FSH. This complementary DNA encodes a protein of 570 amino acids and shares 92% homology with the human MAGE-D protein. In contrast to other MAGE genes (A, B, or C), we have shown that MAGE-D expression was ubiquitous in healthy rat tissues. In the seminiferous tubules, the MAGE-D was expressed in Sertoli cells but not in germ cells as demonstrated by RT-PCR and in situ hybridization, whereas for the other MAGE genes, expression has been shown to be restricted to germ cells. Interestingly, MAGE-D was also detected for the first time in the female gonad by Northern blotting. In MLTC-1 cells (mouse Leydig tumor cell line-1), LH and PRL stimulated MAGE-D expression. Using hypophysectomized rats, it was confirmed that FSH decreased MAGE-D expression, whereas LH and PRL increased MAGE-D messenger RNA level in the whole testis most probably through a direct action on Leydig cells. As MAGE-D is present in both the seminiferous compartment and interstitium and hormonally regulated in each, it is possible that it has specific functions in each compartment during the development and the maintenance of the testis.

Retrospective analysis of 29 patients surgically treated for hepatocellular adenoma or focal nodular hyperplasia

BACKGROUND/AIMS

Hepatocellular adenoma resection and focal nodular hyperplasia supervision are widely recognized as the best management when these benign liver tumors are diagnosed. Differential diagnosis is thus mandatory.

METHODOLOGY

Twenty-nine patients with a presumed benign liver tumor were retrospectively analyzed.

RESULTS

Histopathological analysis of these resected liver tumors demonstrated hepatocellular adenoma in 16 patients and focal nodular hyperplasia in 13. One hepatocellular carcinoma was disclosed into a hepatocellular adenoma and 2 hepatocellular adenoma showed foci of liver-cell dysplasia. Seven patients with hepatocellular adenoma (43%) had evidence of intratumoral hemorrhage, among which 3 patients were admitted with intraperitoneal tumoral rupture. Computed tomography, performed in 26 patients, was the most reliable examination to characterize these presumed benign liver tumors. Magnetic resonance imaging concerned only 5 patients but 3 hepatocellular adenoma and 1 focal nodular hyperplasia were diagnosed. The indications of focal nodular hyperplasia surgical resection were chronic pain (4 pts), hepatocellular adenoma diagnosis (4 pts), undeterminate liver mass (2 pts), a liver mass of unknown origin in patients with a neoplastic history (3 pts). A diagnosis of focal nodular hyperplasia assumed by the imaging work-up was always histologically confirmed. All the patients underwent hepatic resection with no mortality.

CONCLUSIONS

This report underlines the risk of hemorrhage or malignant transformation of hepatocellular adenoma that justifies a safety surgical resection. An imaging work-up in favor of focal nodular hyperplasia allows radiological observation.

The management of pancreatic ascites and pancreaticopleural effusion

Pancreatic ascites and pancreaticopleural effusion result from a complete or partial main pancreatic duct disruption or from a pseudocyst rupture with releasing of pancreatic juice into the surrounding tissues. The treatment requires to minimize pancreatic secretion, to favor pancreatic juice drainage into the digestive tract and to restore main pancreatic duct disruption. This can be achieved by endoscopic approach in more than 90% of the patients.

Genes upregulated during castration-induced rat prostatic apoptosis: cloning and characterization of new cDNAs

OBJECTIVE

To isolate new cDNAs corresponding to genes whose expression is increased during castration-induced rat prostate apoptosis.

MATERIALS AND METHODS

Differential display of mRNAs from 3-day castrated and normal rat ventral prostates was used to identify differentially expressed clones. Northern blots were hybridized to confirm the positive regulation of the candidates and to follow the change in their expression in the involuting rat prostate, and in thymocytes of dexamethazone-treated rats.

RESULTS

Five cDNAs were cloned: one encoding ribosomal protein L7, one coding for the insulin-like growth factor binding protein-3 (IGFBP-3), and three whose products are unknown. After castration, all five genes had expression kinetics that closely paralleled the proportion of prostatic epithelial cells undergoing apoptosis. The gene encoding L7 and two of the unknown genes were also upregulated in glucocorticoid-induced programmed death in thymocytes. In addition to the IGFBP-3 gene, those coding for proteins IGFBP-4, -5 and -6 were also overexpressed in the involuting prostate of androgen-deprived rats.

CONCLUSION

Five new genes were identified that are up-regulated during castration-induced rat prostate apoptosis, three of which are potentially involved in the common intracellular pathway leading to programmed cell death.

[Digestive emergencies of elderly patients]

Evaluation of an elderly patient with acute abdominal conditions presents a challenge to the physician on account of the general poverty of history and clinical signs and the poor reliability of diagnostic procedures. The management of these pathologies are analyzed: cholecystitis, appendicitis, incarcerated hernia, small bowel obstruction, côlonic diverticular disease, intestinal ischemia and gastroduodenal ulcer. An early elective treatment of chronic pathologies like gallstones, hernias and intestinal ischemia trends to avoid complications.

A novel gene overexpressed in the prostate of castrated rats: hormonal regulation, relationship to apoptosis and to acquired prostatic cell androgen independence

We have identified a novel complementary DNA (cDNA) corresponding to a gene overexpressed in the rat ventral prostate after castration. This cDNA displays 89.4% identity with 453 bp of a mouse EST and 81.5% identity with 157 bp of a human EST and was named PARM-1 for prostatic androgen-repressed message-1. The complete cDNA is 1187 bp long and codes for a protein of 298 amino acids that contains four potential glycosylation sites and three half cystinyl residues. The PARM-1 gene was found to be expressed at quite low levels in most rat tissues including those of the urogenital tract. The kinetic of induction of PARM-1 gene in the prostate was highly correlated to the development of apoptosis in the whole organ. Supplementation of castrated animals with androgens reversed both the process of apoptosis and the overexpression of PARM-1 gene. Supplementation with estrogens did not result in an increase in the PARM-1 messenger RNA levels when compared with the castration alone. However, the treatment resulted in a more rapid return to intact levels in the castrated plus estrogen group. When apoptosis of testis and prostate was induced in vivo by hypophysectomy, it was found that PARM-1 was only overexpressed in the prostate. Therefore, PARM-1 seems to be regulated by androgens only in the prostate. Using in situ hybridization and immunohistological techniques, we have shown that PARM-1 gene product is found exclusively in the epithelial cells of involuting prostate. Analysis by flow cytometry of MAT LyLu epithelial cells transiently expressing PARM-1 protein did not allow us to demonstrate a direct effect of PARM-1 gene overexpression on the programmed death of the transfected cells. Treatment of MAT LyLu cells by transforming growth factor-beta induced apoptosis but had no effect on PARM-1 production. However PARM-1 protein has been detected by Western blotting in various cell lines such as MAT LyLu, MAT Lu, and PIF, which are androgen independent. This would suggest that PARM-1 gene product would be a marker for acquired androgen-independence of these tumor cells.

Hepatocellular carcinoma: surgical treatment and prognostic variables in 56 patients

BACKGROUND/AIMS

Partial hepatectomy (PH) or total hepatectomy and orthotopic liver transplantation (OLT) may be curative in selected patients treated for hepatocellular carcinoma (HCC). The analysis of clinical series may help in the choice of the more appropriate treatment.

METHODOLOGY

During the past 11 years, 40 patients with HCC were treated by PH and 16 patients underwent total hepatectomy and OLT. Selection criteria for transplantation were the liver function and the tumor resectability.

RESULTS

The actuarial 1-, 3- and 5-year survival rates were 67%, 34% and 18%, respectively, after PH and 62%, 54% and 54% after OLT. The only prognostic factor after PH was the tumor extension to a single or both lobes. Patients with associated cirrhosis had significantly more post-operative complications, but a comparable long-term survival. The proliferative cell nuclear antigen labeling index (PCNA-LI), evaluated on tumoral tissue in 16 patients, showed that an index <30% indicates a better prognosis for HCC developing in non-cirrhotic liver.

CONCLUSIONS

For patients carefully pre-operatively evaluated, the presence of an associated cirrhosis does not seem to modify the long-term survival after PH, and OLT may offer more than 50% 5-year survival. A PCNA-LI <30% appears to be a good prognostic factor in patients without cirrhosis.

Effects of pituitary hormones on the prostate

BACKGROUND

Although essential, androgens alone are not sufficient to induce normal growth and functionality of the prostate. Nonandrogenic hormones must also be involved in the proliferation of the prostate cancer cells which do not respond to antiandrogenic therapy and which thus become androgen-independent. Prolactin, but also growth hormone and luteinizing hormone, are potentially able to act on both normal and abnormal prostatic cells.

METHODS

In this review we summarize data from the literature concerning the physiological and pathological implications of prolactin, growth hormone, and luteinizing hormone on the prostate.

RESULTS

In rodent prostates, prolactin and growth hormone can induce a variety of effects independently of androgens (e.g., transactivation of certain genes, or synthesis of the major secretion products). Moreover, hyperprolactinemia is responsible for inflammation and dysplasia of the gland, while growth hormone promotes the development of prostate tumors in vivo in the mouse and rat. Growth hormone acts on the gland directly, through prostatic growth hormone receptors, and/or indirectly via the stimulation of insulin-like growth factor-I (IGF-I) synthesis in the liver. Luteinizing hormone receptor is expressed in rat and human prostates. Luteinizing hormone increases the amount of various transcripts in the rat prostate through an androgen-independent pathway.

CONCLUSIONS

Prolactin, growth hormone, and luteinizing hormone, alone or synergistically with androgens, play physiologically significant roles in the normal prostate. The involvement of these hormones in the development of benign prostatic hyperplasia and prostatic carcinoma is an issue that needs to be addressed.

Contribution of computed tomography to decision making in the management of adhesive small bowel obstruction

BACKGROUND

In adhesive small bowel obstruction, the early recognition of complications such as strangulation or volvulus is essential to choose between surgical or conservative initial treatment. The objective of this study was to determine prospectively the contribution of computed tomography (CT) to decision making in the management of these patients.

METHODS

Patients with suspected adhesive small bowel obstruction had CT at admission. Patients with CT signs of volvulus or strangulation and/or clinical signs of peritoneal irritation underwent urgent surgery; other patients had conservative initial treatment.

RESULTS

Fifty-four patients were evaluated. CT demonstrated signs of strangulation or volvulus in 19 patients, including three with signs of peritoneal irritation. Within this group, urgent laparotomy was performed in 17 patients and confirmed the CT diagnosis in 16. Thirty-seven patients without clinical or CT signs of complications had initial conservative treatment; among them, seven of 12 with a distal obstruction determined by CT required a delayed operation for persisting obstruction, compared with two of 25 patients with a proximal obstruction (P < 0.01).

CONCLUSION

CT is useful for the evaluation of adhesive small bowel obstruction, to detect accurately patients with complications who require urgent operation and to determine the location of the adhesion, which represents a significant prognostic factor for success of conservative treatment.

Luteinizing hormone increases the abundance of various transcripts, independently of the androgens, in the rat prostate

Differential display analysis was carried out to find, in the rat prostate, genes that could be regulated by Luteinizing Hormone (LH), independently of the androgens. Hypophysectomized and castrated adult rats were treated with either LH, testosterone or saline. Regulated discrete bands have been eluted and reamplified. After Northern blotting, the levels of mRNA corresponding to 8 PCR fragments were significantly increased by LH treatment. None of these inserts were found to be induced by testosterone. One insert was subcloned, sequenced and identified as the ribosomial protein S 23. A competitive RT-PCR assay was carried out on the full length S 23 cDNA and confirmed that its mRNA levels were stimulated by LH but not by testosterone. These results strongly suggest that the LH membrane receptor, previously shown to be expressed in the rat prostate, has a physiological significance in this organ. Moreover, it appears that the effect of LH on the rat prostate are independent of the androgens.

Nonfunctioning neuroendocrine tumors of the pancreas: clinical presentation of 7 patients

BACKGROUND

Neuroendocrine tumors of the pancreas (NPT) are rare and represent less than 0.5% of all pancreatic tumors.

MATERIALS AND METHODS

The authors describe the clinical presentation, the pathological findings and the treatment of 7 patients with nonfunctioning NPT.

RESULTS

Non-specific symptoms were noted in 6 patients, depending on the size and the location of the tumor, and 1 patient was asymptomatic. A correct preoperative diagnosis was done in only one case. Immunohistochemical studies, most often on surgically resected tissue sample is needed for diagnosis of NPT. The treatment requires surgical resection. Among 4 patients (57%) classified No at the time of surgery, 3 (75%) are alive, free of recurrence, more than 2 years after tumor resection.

CONCLUSION

The preoperative diagnosis is difficult to assess. NPT differ from pancreatic adenocarcinomas by the younger age of the patients, their immunohistochemical pattern and a better prognosis after surgical resection.

Pituitary control of proliferation and differentiation of Leydig cells and their putative precursors in immature hypophysectomized rat testis

The objective of this study was to determine the effects of pituitary hormones (luteinizing hormone [LH], follicle-stimulating hormone [FSH], growth hormone [GH], and prolactin [PRL]) on interstitial cell proliferation and differentiation in the testis of immature hypophysectomized rats. Macrophages, Leydig cells, precursor mesenchymal cells, endothelial lymphatic cells, and myoid cells were studied. Our experimental approach was aimed at determining whether changes in a cellular subpopulation observed after pituitary hormone treatments were the result of division of existing cells in the population, of differentiation of interstitial precursor cells, or both. In this context, it must be stressed that our data reflected the effects of hormones to prevent the decline of cells due to hypophysectomy rather than their recovery. Macrophage proliferation was taken into account because macrophages closely resemble Leydig cells and are known to proliferate after hormonal treatment. A double-labeling procedure (acid phosphatase and anti-bromodeoxyuridine [anti-BUdR]) revealed that LH, FSH, and PRL increased the number of testicular macrophages 105-, 104-, and 103-fold, respectively, in hypophysectomized rats compared to hypophysectomized control animals. BUdR incorporation in testicular macrophages was greater after PRL treatment than after LH and FSH supplementation. In contrast, we were unable to demonstrate any effect of rat GH on the macrophage population. Light microscopic analysis of plastic embedded sections of treated rat testis revealed that LH increased the numbers of Leydig, precursor mesenchymal, and myoid cells 6-, 4-, and 1.3-fold, respectively. LH also stimulated BUdR incorporation into all interstitial cell types. PRL administration increased both the number of Leydig and precursor mesenchymal cells (each 3-fold) but decreased the number of endothelial lymphatic cells (1.5-fold) when compared to the control animals. In contrast, FSH did not increase the number and proliferation of Leydig cells but exerted a slight proliferative effect on the other interstitial cell populations. In GH-treated rats, the number of precursor mesenchymal cells increased two fold above the control rats. GH also exerted slight proliferative effects on both precursor mesenchymal and myoid cells. Immunohistochemical studies of steroidogenic enzymes in the testicular interstitium of treated rats demonstrated the presence of steroidogenic enzymes, not only in Leydig and precursor mesenchymal cells, but also in some (1%-2%) endothelial lymphatic cells and myoid cells. This may indicate that both of these cell types are also constitutively equipped to perform steroidogenesis or that they are precursor cells undergoing differentiation. Taken together, changes in the number of Leydig cells in our animal model appeared more likely to be dependent on the transformation of precursor cells than on division of preexisting mature Leydig cells.

[The treatment of morbid obesity with gastroplasty]

Morbid obesity is related to a severe decrease in life expectancy. No medical or dietary treatment offers an alternative to control hypertension, apnea syndrome, orthopedic diseases, ..., caused by overweight. With respect to a serious preoperative evaluation and a severe selection (psychologic, dietetic, ...) Silastic Ring Vertical Gastroplasty is considered in our experience (more than 300 cases) and in the literature as the gold standard for surgical treatment of obesity. The long term follow-up (24-66 months) of 100 consecutive operated patients shows a positive response on hypertension (96%), apnea syndrome (92%), diabetes (85%), gastroesophageal reflux (76%), orthopedic diseases (74%) and cardiorespiratory insufficiency (74%). Considering our experience in the medical and surgical management of patients operated in our department or referred from other centers for complications after different procedures, we actually propose SRVG as the treatment of choice for morbid obesity.

Laparoscopic treatment of a sigmoid perforation after colonoscopy. Case report and review of literature

The authors report a case of sigmoid colon perforation post colonoscopic polypectomy. Such perforation is rare and has been estimated to occur between 0.1 and 3% of the time. Surgical treatment is necessary when there is deterioration of the clinical state. In this reported case, surgical closure of the perforation was achieved by laparoscopy. We believe that this approach is effective for colonic suture, peritoneal lavage, and drainage.

Delayed enhancement of the bowel wall: a new CT sign of small bowel strangulation

PURPOSE

To report a new CT sign of small bowel strangulation.

MATERIALS AND METHODS

Two cases of small bowel obstruction evaluated by spiral CT with intravenous contrast injection.

RESULTS

In both cases we observed an absence of parietal enhancement of the diseased bowel loop, visible on early scans only. This feature was accompanied by signs of bowel obstruction. The two patients had a segment of necrotic ileum resected.

CONCLUSION

Delayed enhancement of a bowel loop in cases of small bowel obstruction should suggest the diagnosis of strangulation and lead to rapid surgical treatment.