Target fishing reveals PfPYK-1 and PfRab6 as potential targets of an antiplasmodial 4-anilino-2-trichloromethylquinazoline hit compound

We present investigations about the mechanism of action of a previously reported 4-anilino-2-trichloromethylquinazoline antiplasmodial hit-compound (Hit A), which did not share a common mechanism of action with established commercial antimalarials and presented a stage-specific effect on the erythrocytic cycle of P. falciparum at 8 < t < 16 h. The target of Hit A was searched by immobilising the molecule on a solid support via a linker and performing affinity chromatography on a plasmodial lysate. Several anchoring positions of the linker (6,7 and 3') and PEG-type linkers were assessed, to obtain a linked-hit molecule displaying in vitro antiplasmodial activity similar to that of unmodified Hit A. This allowed us to identify the PfPYK-1 kinase and the PfRab6 GTP-ase as potential targets of Hit A.

Novel thienopyrimidones targeting hepatic and erythrocytic stages of Plasmodium parasites with increased microsomal stability

Based on the structure of a previously identified hit, Gamhepathiopine 1, which showed promising antiplasmodial activity, but poor microsomal stability, several strategies were investigated to improve the metabolic stability of the compounds. This included the introduction of fluorine or deuterium atoms, as well as carbocyclic groups. Among the new compounds, the 2-aminocyclobutyl derivative 5g demonstrated enhanced microsomal stability compared to compound 1, while retaining antiplasmodial activity against erythrocytic and hepatic stages of Plasmodium, without significant cytotoxicity against primary hepatocytes.

New antiplasmodial 4-amino-thieno[3,2-d]pyrimidines with improved intestinal permeability and microsomal stability

The increasing number of Plasmodium falciparum strains resistant to current treatments justifies the urgent need to discover new compounds active on several stages of the parasite development. Based on the structure of Gamhepathiopine, a 2-tert-butylaminothieno[3,2-d]pyrimidin-4(3H)-one previously identified for its dual activity against the sexual and asexual stages of P. falciparum, 25 new 4-amino-substituted analogues were synthesized and evaluated on the erythrocytic and hepatic stages of Plasmodium. A promising compound, N2-(tert-butyl)-N [4]-(3-(dimethylamino)propyl)-6-(p-tolyl)thieno[3,2-d]pyrimidine-2,4-diamine, showed improved physicochemical properties, intestinal permeability (PAMPA model) and microsomal stability compared to Gamhepathiopine, while maintaining a good antiplasmodial activity on the erythrocytic stage of P. falciparum and on the hepatic stage of P. berghei.

Improving Aqueous Solubility and In Vitro Pharmacokinetic Properties of the 3-Nitroimidazo[1,2-a]pyridine Antileishmanial Pharmacophore

An antileishmanial structure−activity relationship (SAR) study focused on positions 2 and 8 of the imidazo[1,2-a]pyridine ring was conducted through the synthesis of 22 new derivatives. After being screened on the promatigote and axenic amastigote stages of Leishmania donovani and L. infantum, the best compounds were tested against the intracellular amastigote stage of L. infantum and evaluated regarding their in vitro physicochemical and pharmacokinetic properties, leading to the discovery of a new antileishmanial6-chloro-3-nitro-8-(pyridin-4-yl)-2-[(3,3,3-trifluoropropylsulfonyl)methyl]imidazo[1,2-a]pyridine hit. It displayed low cytotoxicities on both HepG2 and THP1 cell lines (CC50 > 100 µM) associated with a good activity against the intracellular amastigote stage of L. infantum (EC50 = 3.7 µM versus 0.4 and 15.9 µM for miltefosine and fexinidazole, used as antileishmanial drug references). Moreover, in comparison with previously reported derivatives in the studied series, this compound displayed greatly improved aqueous solubility, good mouse microsomal stability (T1/2 > 40 min) and high gastrointestinal permeability in a PAMPA model, making it an ideal candidate for further in vivo studies on an infectious mouse model.

Synthesis of antiplasmodial 2-aminothieno[3,2-d]pyrimidin-4(3H)-one analogues using the scaffold hopping strategy

Gamhepathiopine (also known as M1), is a multi-stage acting antiplasmodial 2-tert-butylaminothieno[3,2-d]pyrimidin-4(3H)-one hydrochloride that was first described in 2015. The development of this compound is limited by poor microsomal stability, insufficient aqueous solubility and low intestinal permeability. In order to obtain new optimized derivatives, we conducted a scaffold hopping strategy from compound M1, resulting in the synthesis of 20 new compounds belonging to six chemical series. All the compounds were tested on the K1 multi-resistant strain of Plasmodium falciparum and the human HepG2 cell-line, to evaluate their antiplasmodial activity and their cytotoxicity. Analogues' biological results also highlighted the mandatory presence of a heteroatom at position 5 of the thieno[3,2-d]pyrimidin-4(3H)-one moeity for the antiplasmodial activity. However, modifications at position 7 were detrimental for the antiplasmodial activity. We identified furane bioisostere 3j as a promising candidate, showing good blood stage antiplasmodial activity, better water solubility and highly improved intestinal permeability in the PAMPA assay.

Pd-catalyzed C-C and C-N cross-coupling reactions in 2-aminothieno[3,2-d]pyrimidin-4(3H)-one series for antiplasmodial pharmacomodulation

In 2015, we identified gamhepathiopine (M1), a 2-tert-butylaminothieno[3,2-d]pyrimidin-4(3H)-one antiplasmodial hit targeting all development stages of the human malarial parasite P. falciparum. However, this hit compound suffers from sensitivity to hepatic oxidative metabolism. Herein, we describe the synthesis of 33 new compounds in the 2-aminothieno[3,2-d]pyrimidin-4(3H)-one series modulated at position 6 of this scaffold. The modulations were performed using three palladium-catalyzed cross coupling reactions, namely Suzuki-Miyaura, Sonogashira, and Buchwald-Hartwig. For the latter, we developed the reaction conditions. Then, we evaluated the synthesized compounds for their antiplasmodial activity on the K₁ P. falciparum strain and their cytotoxicity on the human HepG2 cell line. Although we did not obtain a compound better than M1 in terms of the antiplasmodial activity, we identified compound 1g bearing a piperidine at position 6 of the thieno[3,2-d]pyrimidin-4(3H)-one ring with an improved cytotoxicity and metabolic stability. 1g is an interesting new starting point for further pharmacomodulation studies. This study also provides valuable antiplasmodial SAR data regarding the nature of the ring at position 6, the possible substituent on this ring, and the introduction of a spacer between this ring and the thienopyrimidinone moiety.

Star-like poly(peptoid)s with selective antibacterial activity

We developed new macromolecular engineering approaches enabling the preparation of star-shaped and antimicrobial polypeptoids by ring-opening polymerization.

Effect of N-alkylation in N-carboxyanhydride (NCA) ring-opening polymerization kinetics

N-carboxyanhydrides ring-opening polymerization (ROP) showed that electron-donating groups of the N-alkylation enhanced the ROP kinetic rates through an inductive effect that could counterbalance the steric hindrance during the propagation.

Antiplasmodial 2-thiophenoxy-3-trichloromethyl quinoxalines target the apicoplast of Plasmodium falciparum

The identification of a plant-like Achille's Heel relict, i.e. the apicoplast, that is essential for Plasmodium spp., the causative agent of malaria lead to an attractive drug target for new antimalarials with original mechanism of action. Although it is not photosynthetic, the apicoplast retains several anabolic pathways that are indispensable for the parasite. Based on previously identified antiplasmodial hit-molecules belonging to the 2-trichloromethylquinazoline and 3-trichloromethylquinoxaline series, we report herein an antiplasmodial Structure-Activity Relationships (SAR) study at position two of the quinoxaline ring of 16 newly synthesized compounds. Evaluation of their activity toward the multi-resistant K1 Plasmodium falciparum strain and cytotoxicity on the human hepatocyte HepG2 cell line revealed a hit compound (3k) with a PfK1 EC₅₀ value of 0.3 μM and a HepG2 CC₅₀ value of 56.0 μM (selectivity index = 175). Moreover, hit-compound 3k was not cytotoxic on VERO or CHO cell lines and was not genotoxic in the in vitro comet assay. Activity cliffs were observed when the trichloromethyl group was replaced by CH₃, CF₃ or H, showing that this group played a key role in the antiplasmodial activity. Biological investigations performed to determine the target and mechanism of action of the compound 3k strongly suggest that the apicoplast is the putative target as showed by severe alteration of apicoplaste biogenesis and delayed death response. Considering that there are very few molecules that affect the Plasmodium apicoplast, our work provides, for the first time, evidence of the biological target of trichloromethylated derivatives.

2-Phenoxy-3-Trichloromethylquinoxalines Are Antiplasmodial Derivatives with Activity against the Apicoplast of Plasmodium falciparum

The malaria parasite harbors a relict plastid called the apicoplast. Although not photosynthetic, the apicoplast retains unusual, non-mammalian metabolic pathways that are essential to the parasite, opening up a new perspective for the development of novel antimalarials which display a new mechanism of action. Based on the previous antiplasmodial hit-molecules identified in the 2-trichloromethylquinoxaline series, we report herein a structure–activity relationship (SAR) study at position two of the quinoxaline ring by synthesizing 20 new compounds. The biological evaluation highlighted a hit compound (3i) with a potent PfK1 EC₅₀ value of 0.2 µM and a HepG2 CC₅₀ value of 32 µM (Selectivity index = 160). Nitro-containing (3i) was not genotoxic, both in the Ames test and in vitro comet assay. Activity cliffs were observed when the 2-CCl₃ group was replaced, showing that it played a key role in the antiplasmodial activity. Investigation of the mechanism of action showed that 3i presents a drug response by targeting the apicoplast and a quick-killing mechanism acting on another target site.

Cyclic Poly(α-peptoid)s by Lithium bis(trimethylsilyl)amide (LiHMDS)-Mediated Ring-Expansion Polymerization: Simple Access to Bioactive Backbones

Cyclic polymers display unique physicochemical and biological properties. However, their development is often limited by their challenging preparation. In this work, we present a simple route to cyclic poly(α-peptoids) from N-alkylated-N-carboxyanhydrides (NNCA) using LiHMDS promoted ring-expansion polymerization (REP) in DMF. This new method allows the unprecedented use of lysine-like monomers in REP to design bioactive macrocycles bearing pharmaceutical potential against Clostridioides difficile, a bacterium responsible for nosocomial infections.

Synthetic Polypeptide Polymers as Simplified Analogues of Antimicrobial Peptides

Antimicrobial peptides (AMPs) are naturally occurring macromolecules made of amino acids that are potent broad-spectrum antibiotics with potential as novel therapeutic agents. This review aims to summarize the fundamental principles concerning the structure and mechanism of action of these AMPs, in order to guide the design of polymeric analogues that organic chemistry can generate. Among those simplified analogues, this review particularly focuses on those made of amino acids called polypeptide polymers: they are showing great potential by providing one of the best biomimetic and bioactive structures for further biomaterials science applications.

8-Alkynyl-3-nitroimidazopyridines display potent antitrypanosomal activity against both T. b. brucei and cruzi

An antikinetoplastid pharmacomodulation study was done at position 8 of a previously identified pharmacophore in 3-nitroimidazo[1,2-a]pyridine series. Twenty original derivatives bearing an alkynyl moiety were synthesized via a Sonogashira cross-coupling reaction and tested in vitro, highlighting 3 potent (40 nM ≤ EC₅₀ blood stream form≤ 70 nM) and selective (500 ≤ SI ≤ 1800) anti-T. brucei brucei molecules (19, 21 and 22), in comparison with four reference drugs. Among these hit molecules, compound 19 also showed the same level of activity against T. cruzi (EC₅₀ amastigotes = 1.2 μM) as benznidazole and fexinidazole. An in vitro comet assay showed that nitroaromatic derivative 19 was not genotoxic. It displayed a low redox potential value (-0.68 V/NHE) and was shown to be bioactivated by type 1 nitroreductases both in Leishmania and Trypanosoma. The SAR study indicated that an alcohol function improved aqueous solubility while maintaining good activity and low cytotoxicity when the hydroxyl group was at position beta of the alkyne triple bond. Hit-compound 19 was also evaluated regarding in vitro pharmacokinetic data: 19 is BBB permeable (PAMPA assay), has a 16 min microsomal half-life and a high albumin binding (98.5%). Moreover, compound 19 was orally absorbed and was well tolerated in mouse after both single and repeated administrations at 100 mg/kg. Its mouse plasma half-life (10 h) is also quite encouraging, paving the way toward further efficacy evaluations in parasitized mouse models, looking for a novel antitrypanosomal lead compound.

New 8-Nitroquinolinone Derivative Displaying Submicromolar in Vitro Activities against Both Trypanosoma brucei and cruzi

An antikinetoplastid pharmacomodulation study was conducted at position 6 of the 8-nitroquinolin-2(1H)-one pharmacophore. Fifteen new derivatives were synthesized and evaluated in vitro against L. infantum, T. brucei brucei, and T. cruzi, in parallel with a cytotoxicity assay on the human HepG2 cell line. A potent and selective 6-bromo-substituted antitrypanosomal derivative 12 was revealed, presenting EC₅₀ values of 12 and 500 nM on T. b. brucei trypomastigotes and T. cruzi amastigotes respectively, in comparison with four reference drugs (30 nM ≤ EC₅₀ ≤ 13 μM). Moreover, compound 12 was not genotoxic in the comet assay and showed high in vitro microsomal stability (half life >40 min) as well as favorable pharmacokinetic behavior in the mouse after oral administration. Finally, molecule 12 (E° = -0.37 V/NHE) was shown to be bioactivated by type 1 nitroreductases, in both Leishmania and Trypanosoma, and appears to be a good candidate to search for novel antitrypanosomal lead compounds.

Nongenotoxic 3-Nitroimidazo[1,2-a]pyridines Are NTR1 Substrates That Display Potent in Vitro Antileishmanial Activity

Twenty nine original 3-nitroimidazo[1,2-a]pyridine derivatives, bearing a phenylthio (or benzylthio) moiety at position 8 of the scaffold, were synthesized. In vitro evaluation highlighted compound 5 as an antiparasitic hit molecule displaying low cytotoxicity for the human HepG2 cell line (CC₅₀ > 100 μM) alongside good antileishmanial activities (IC₅₀ = 1-2.1 μM) against L. donovani, L. infantum, and L. major; and good antitrypanosomal activities (IC₅₀ = 1.3-2.2 μM) against T. brucei brucei and T. cruzi, in comparison to several reference drugs such as miltefosine, fexinidazole, eflornithine, and benznidazole (IC₅₀ = 0.6 to 13.3 μM). Molecule 5, presenting a low reduction potential (E° = -0.63 V), was shown to be selectively bioactivated by the L. donovani type 1 nitroreductase (NTR1). Importantly, molecule 5 was neither mutagenic (negative Ames test), nor genotoxic (negative comet assay), in contrast to many other nitroaromatics. Molecule 5 showed poor microsomal stability; however, its main metabolite (sulfoxide) remained both active and nonmutagenic, making 5 a good candidate for further in vivo studies.

Antitrypanosomatid Pharmacomodulation at Position 3 of the 8-Nitroquinolin-2(1H)-one Scaffold Using Palladium-Catalysed Cross-Coupling Reactions

An antikinetoplastid pharmacomodulation study at position 3 of the recently described hit molecule 3-bromo-8-nitroquinolin-2(1H)-one was conducted. Twenty-four derivatives were synthesised using the Suzuki-Miyaura cross-coupling reaction and evaluated in vitro on both Leishmania infantum axenic amastigotes and Trypanosoma brucei brucei trypomastigotes. Introduction of a para-carboxyphenyl group at position 3 of the scaffold led to the selective antitrypanosomal hit molecule 3-(4-carboxyphenyl)-8-nitroquinolin-2(1H)-one (21) with a lower reduction potential (-0.56 V) than the initial hit (-0.45 V). Compound 21 displays micromolar antitrypanosomal activity (IC50 =1.5 μm) and low cytotoxicity on the human HepG2 cell line (CC50 =120 μm), having a higher selectivity index (SI=80) than the reference drug eflornithine. Contrary to results previously obtained in this series, hit compound 21 is inactive toward L. infantum and is not efficiently bioactivated by T. brucei brucei type I nitroreductase, which suggests the existence of an alternative mechanism of action.

Anticancer and Anti-Inflammatory Activities of Some New Pyrazolo[3,4-b]pyrazines

New derivatives of pyrazolo[3,4-b]pyrazines and related heterocycles were synthesized using 5-amino-3-methyl-4-nitroso-1-phenyl-pyrazole (1) as a starting material. The 5-acetyl derivative 15 was shown to be a useful key intermediate for the synthesis of several derivatives of pyrazolopyrazines. Some of the prepared compounds were evaluated for their anti-inflammatory and anti-breast cancer MCF-7 cell line activities. SAR study showed that compounds 15 and 29 exhibited remarkable anti-inflammatory activity, where 15 showed the same activity as that of the reference drug indomethacin. On the other hand, compounds 25i, 25j showed very significant inhibitory activity (p < 0.001) against MCF-7 breast cancer cell line.

8-Aryl-6-chloro-3-nitro-2-(phenylsulfonylmethyl)imidazo[1,2-a]pyridines as potent antitrypanosomatid molecules bioactivated by type 1 nitroreductases

Based on a previously identified antileishmanial 6,8-dibromo-3-nitroimidazo[1,2-a]pyridine derivative, a Suzuki-Miyaura coupling reaction at position 8 of the scaffold was studied and optimized from a 8-bromo-6-chloro-3-nitroimidazo[1,2-a]pyridine substrate. Twenty-one original derivatives were prepared, screened in vitro for activity against L. infantum axenic amastigotes and T. brucei brucei trypomastigotes and evaluated for their cytotoxicity on the HepG2 human cell line. Thus, 7 antileishmanial hit compounds were identified, displaying IC50 values in the 1.1-3 μM range. Compounds 13 and 23, the 2 most selective molecules (SI = >18 or >17) were additionally tested on both the promastigote and intramacrophage amastigote stages of L. donovani. The two molecules presented a good activity (IC50 = 1.2-1.3 μM) on the promastigote stage but only molecule 23, bearing a 4-pyridinyl substituent at position 8, was active on the intracellular amastigote stage, with a good IC50 value (2.3 μM), slightly lower than the one of miltefosine (IC50 = 4.3 μM). The antiparasitic screening also revealed 8 antitrypanosomal hit compounds, including 14 and 20, 2 very active (IC50 = 0.04-0.16 μM) and selective (SI = >313 to 550) molecules toward T. brucei brucei, in comparison with drug-candidate fexinidazole (IC50 = 0.6 & SI > 333) or reference drugs suramin and eflornithine (respective IC50 = 0.03 and 13.3 μM). Introducing an aryl moiety at position 8 of the scaffold quite significantly increased the antitrypanosomal activity of the pharmacophore. Antikinetoplastid molecules 13, 14, 20 and 23 were assessed for bioactivation by parasitic nitroreductases (either in L. donovani or in T. brucei brucei), using genetically modified parasite strains that over-express NTRs: all these molecules are substrates of type 1 nitroreductases (NTR1), such as those that are responsible for the bioactivation of fexinidazole. Reduction potentials measured for these 4 hit compounds were higher than that of fexinidazole (-0.83 V), ranging from -0.70 to -0.64 V.

Novel 8-nitroquinolin-2(1H)-ones as NTR-bioactivated antikinetoplastid molecules: Synthesis, electrochemical and SAR study

To study the antiparasitic 8-nitroquinolin-2(1H)-one pharmacophore, a series of 31 derivatives was synthesized in 1-5 steps and evaluated in vitro against both Leishmania infantum and Trypanosoma brucei brucei. In parallel, the reduction potential of all molecules was measured by cyclic voltammetry. Structure-activity relationships first indicated that antileishmanial activity depends on an intramolecular hydrogen bond (described by X-ray diffraction) between the lactam function and the nitro group, which is responsible for an important shift of the redox potential (+0.3 V in comparison with 8-nitroquinoline). With the assistance of computational chemistry, a set of derivatives presenting a large range of redox potentials (from -1.1 to -0.45 V) was designed and provided a list of suitable molecules to be synthesized and tested. This approach highlighted that, in this series, only substrates with a redox potential above -0.6 V display activity toward L. infantum. Nevertheless, such relation between redox potentials and in vitro antiparasitic activities was not observed in T. b. brucei. Compound 22 is a new hit compound in the series, displaying both antileishmanial and antitrypanosomal activity along with a low cytotoxicity on the human HepG2 cell line. Compound 22 is selectively bioactivated by the type 1 nitroreductases (NTR1) of L. donovani and T. brucei brucei. Moreover, despite being mutagenic in the Ames test, as most of nitroaromatic derivatives, compound 22 was not genotoxic in the comet assay. Preliminary in vitro pharmacokinetic parameters were finally determined and pointed out a good in vitro microsomal stability (half-life > 40 min) and a 92% binding to human albumin.

Looking for new antiplasmodial quinazolines: DMAP-catalyzed synthesis of 4-benzyloxy- and 4-aryloxy-2-trichloromethylquinazolines and their in vitro evaluation toward Plasmodium falciparum

A DMAP catalyzed synthesis of new 4-benzyloxy- and 4-aryloxy-2-trichloromethylquinazolines was studied, in a view to react 4-chloroquinazolines with poorly nucleophilic alcohols such as benzylic alcohols, via a simple and cheap SNAr reaction approach. A fast (1 h) general operating procedure, affording good reaction yields, was achieved under microwave irradiation. Thus, a series of 35 molecules was obtained and evaluated in vitro on the K1 multi-resistant Plasmodium falciparum strain, in parallel with a cytotoxicity assessment on the human HepG2 cell line. 5 hit-molecules were identified, presenting both promising antiplasmodial activity (1.5 μM < IC50 < 2 μM) and low cytotoxicities (25 μM < CC50 < 45 μM). Apart for 2 molecules, the global series displayed a satisfying solubility in the aqueous biological media. Structure-activity relationships showed that the molecules presenting a benzyloxy moiety were less cytotoxic than the ones bearing a phenoxy moiety at position 4 of the quinazoline ring. It also appeared that the introduction of a heteroaryl moiety afforded inactive compounds. Finally, the most active and selective molecules (Selectivity Index = 22-27) were the ones presenting either an unsubstituted benzyloxy group or a phenoxy group, this last bearing a p-bromo or an o-acetyl substituent.

What to do when it is technically impossible to perform laparoscopic sleeve gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is increasingly popular with surgeons because of its apparent technical ease. However, performing LSG safely is sometimes not possible during laparoscopy. The objectives of the present study were to (i) describe the context of LSG failure and (ii) suggest preoperative care options or strategies that enable secondary LSG to be performed safely.

METHODS

We studied patients having undergone primary and secondary LSG between January 2008 and July 2013. The primary efficacy criterion was the LSG success rate. The secondary efficacy criteria were preoperative care procedures, the complication rate, the failure rate, and the frequency of conversion to open surgery.

RESULTS

During the study period, 954 patients underwent first- or second-line LSG. Laparoscopic sleeve gastrectomy was technically impossible in 12 patients (1.2 %). The cause of failure was a large left liver lobe in seven cases (58.3 %) and a lack of space in five cases. Of these 12 patients, nine underwent secondary LSG. The median preoperative BMI before the first LSG was 51.5 kg/m(2). The median (range) time interval between the two LSG attempts was 6 months (3-37). Prior to secondary LSG, the preoperative weight reduction measure was a diet in seven cases (78 %), an intragastric balloon in one case, and no treatment in one case. The median preoperative excess weight loss (EWL) before the second LSG was 10 % (0-20). Five LSGs were successful, two required conversion to open surgery, and two failed again. There were two postoperative complications (22 %), both of which concerned the two patients with conversion to laparotomy.

CONCLUSIONS

In the event of LSG technical failure, preoperative weight loss may enable a second attempt at laparoscopic treatment. A preoperative EWL of at least 10 % appears to be required for the avoidance of conversion to laparotomy.

Effect of perioperative management on short-term outcomes after sleeve gastrectomy: a 600-patient single-center cohort study

BACKGROUND

Reports on the postoperative outcomes of sleeve gastrectomy (SG) have only been from small, single-center series and meta-analyses of studies with variable SG management. The objective of this study was to evaluate post-SG outcomes in a specialized bariatric surgery center with a routinely performed standardized procedure.

METHODS

The postoperative complication rate, operating times, and postoperative data were evaluated from all patients undergoing a primary SG between November 2004 and February 2012. Results were analyzed for 3 separate surgical periods, which differed with perioperative management.

RESULTS

Of 600 patients (mean age: 41.8±11.3; mean body mass index [BMI]: 47.2±16 kg/m²; 80% were women who underwent primary SG), 26.8% had a BMI≥50 kg/m². The mean operating time was 84 minutes. The rate of conversion was 1%. There were no postoperative deaths. The overall complication rate was 8.5%; the major complication rate was 5.6%; the revisional surgery rate was 4.6% and the gastric leak rate was 2.5%. Over the course of the 3 study periods, the operating time fell from 91±32 to 79±22 minutes (P≤.001); the length of hospital stay decreased from 4.5±4.9 to 3.4±4.3 days (P = .02); the major complication rate fell from 6.4% to 5.5% (P = NS); and the gastric fistula rate decreased from 4.6% to 1.9% (P = NS).

CONCLUSION

In a specialist bariatric surgery center, SG had an acceptable complication rate. Modifications in the perioperative management of SG were associated with a shorter mean operating time and hospital stay and did not increase the major complication or gastric fistula rates.

Two lessons from a 5-year follow-up study of laparoscopic sleeve gastrectomy: persistent, relevant weight loss and a short surgical learning curve

INTRODUCTION

Like Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy (LSG) has been validated as a bariatric surgery procedure in its own right. However, the few studies of the long-term outcomes of LSG have only featured small patient populations. The objective of the present study was to evaluate weight loss 5 years after LSG and assess the surgical learning curve for this procedure.

METHODS

We performed a retrospective, single-center study of a prospective database including all consecutive patients having undergone LSG at Amiens University Medical Center between November 2004 and July 2007. Data (weight, body mass index [BMI], percentage of excess weight loss [EWL], percentage of excess BMI loss, and percentage weight loss [PWL]) were collected during follow-up (particularly after 5 years).

RESULTS

The study population comprised 118 patients (100 females [85%]; mean ± SD age, 40 ± 11 years; mean preoperative weight, 131 ± 22 kg; mean preoperative BMI, 47.7 ± 7 kg/m(2)). LSG was performed after failure of gastric banding in 23 cases (19%) and after failure of an intragastric balloon in 1 (0.8%). In all, 95 patients (81%) were analyzed ≥60 months after the LSG (mean follow-up period, 71 ± 9 months). The PWL and EWL were 25 ± 14% and 46 ± 26%, respectively. Eleven patients had undergone a second bariatric operation within 5 years of the LSG. Concerning the 84 patients in whom only LSG was the only operation, the PWL and EWL were 23 ± 14% and 43 ± 25%, respectively. The EWL was >50% in 35 of these 84 patients (42%) and between 25 and 50% in 30 cases (36%). Optimal weight results were achieved after only 28 LSG had been performed, which testifies to a shorter learning curve than for most other bariatric surgery techniques.

CONCLUSION

Isolated LSG is a quickly mastered bariatric surgery technique with a short learning curve. It enables a mean PWL of >25% and an EWL of >50% in >40% of cases.

Laparoscopic sleeve gastrectomy in patients with NASH-related cirrhosis: a case-matched study

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) is a validated procedure for the surgical treatment of morbid obesity. Cirrhosis is often considered a relative contraindication to elective extrahepatic surgery. The objective of this study was to evaluate the morbidity related to SG performed in cirrhotic patients compared with noncirrhotic patients.

METHODS

Between March 2004 and January 2013, we included all patients with cirrhosis undergoing SG (13 patients). These patients (SG-cirrhosis group) were matched in terms of preoperative data (age, gender, body mass index, and co-morbidities) on a 1:2 basis, with 26 noncirrhotic patients (SG group) selected from a population of 750 patients. Cirrhosis was diagnosed postoperatively on histologic exam. The primary endpoint was the overall postoperative complication rate. Secondary endpoints were operating time, revisional surgery rate, gastric fistula and bleeding rates, postoperative mortality, and weight loss over a 24-month period.

RESULTS

The SG-cirrhosis group consisted of 13 patients with a median age of 52 years. All patients in the SG-cirrhosis group were Child A. Etiology of cirrhosis was related to NASH in 93.3%. Median operating time in the SG-cirrhosis group and SG group was 75 minutes versus 80 minutes (P = .59). No postoperative mortality was observed in either group. The overall postoperative complication rate was 7.7% versus 7.7% (P = 1). The major complication rate was 0% versus 7.7% (P = .22), and the postoperative gastric fistula rate was 0% versus 3.8% (P = .47). No complications related to cirrhosis were reported.

CONCLUSION

SG can be performed in Child A cirrhosis with no increased risk of postoperative complications and no specific complications related to cirrhosis. Weight loss for patients with cirrhosis undergoing SG is similar to that observed in noncirrhotic patients.

Repeat sleeve gastrectomy compared with primary sleeve gastrectomy: a single-center, matched case study

Longitudinal sleeve gastrectomy (LSG) has been validated for the treatment of morbid obesity. However, treatment failures can appear several months after SG. Additional malabsorptive surgery is generally recommended in such cases. The objective of the present study was to evaluate the outcomes of repeat SG (re-SG) relative to first-line SG. This was a retrospective study included 15 patients underwent re-SG after failure of first-line SG (i.e. University Hospital, France; Public Practice). These patients were matched (for age, gender, body mass index and comorbidities) 1:2 with 30 patients having undergone first-line SG. The efficacy criteria comprised intra-operative data and postoperative data. The overall study population comprised 45 patients. The re-SG and first-line SG groups did not differ significantly in terms of median age (p = NS). The median BMI was similar in the two groups (43 kg/m(2) vs. 42.3 kg/m(2), p = NS). The two groups were similar in terms of the prevalence of comorbidities. The mean operating time was longer in the re-SG group (116 vs. 86 min; p ≤ 0.01). The postoperative complication rate was twice as high in the re-SG group (p = 0.31). Two patients in the re-SG group developed a gastric fistula (p = 0.25) and one of the latter died. At 12 months, the Excess Weight Loss was 66% (re-SG group) and 77% (first-line SG group) (p = 0.05). Re-SG is feasible but appears to be associated with a greater risk of complications. Nevertheless, re-SG can produce results (in terms of weight loss), equivalent to those obtained after first-line SG.

Is the residual gastric volume after laparoscopic sleeve gastrectomy an objective criterion for adapting the treatment strategy after failure?

BACKGROUND

Causes of failure after laparoscopic sleeve gastrectomy (LSG) are not known but may include a high residual gastric volume (RGV). The aim of this study was to use gastric computed tomography volumetry (GCTV) to investigate the RGV and relate the latter parameter to the outcome of LSG.

METHODS

A single-center, prospective study included patients with>24 months of follow-up after LSG. The RGV was measured with a unique GCTV technique. We determined the LSG outcomes according to a variety of criteria and examined potential relationships with the RGV. When the RGV was>250 cc, we offered a repeat LSG (RLSG).

RESULTS

Seventy-six patients were included. The mean RGV was 255 cc but differed significantly when comparing "failure" and "success" subgroups, regardless of whether the latter were defined by a percentage of excess weight loss>50 (309 cc versus 225 cc, respectively; P = .0003), a BAROS score>3 (312 cc versus 234 cc; P = .005), the Reinhold criteria (290 cc versus 235 cc; P = .019), or the Biron criteria (308 cc versus 237 cc; P = .008). The RGV threshold (corresponding to the volume above which the probability of failure after LSG is high) was 225 cc. Fifteen RLSGs were performed during the inclusion period.

CONCLUSION

A high RGV 34 months after LSG is a risk factor for failure. Knowledge of the RGV can be of value in the management of failure after LSG.

Simultaneous gastric band removal and sleeve gastrectomy: a comparison with front-line sleeve gastrectomy

The placement of a gastric band (GB) prior to a sleeve gastrectomy (LSG) would increase postoperative complications, whether it is withdrawn or not at the time of the LSG. The purpose of this retrospective study was to evaluate and compare postoperative morbidity and outcome weight for simultaneous GB removal (RGB) and LSG (the RGB + LSG group) and front-line LSG only (the LSG group) after unsuccessful GB. From May 2005 to May 2009, 305 patients underwent first- or second-line LSG at Amiens University Hospital. The primary endpoint was the postoperative complication rate (according to the Clavien classification) in the RGB + LSG and LSG groups. The secondary endpoints were intra-operative data, postoperative data, and weight loss over a period of 2 years (body mass index, percentage of excess weight loss, and percentage of excess body mass index (BMI) loss). Univariate and multivariate propensity score analyses were used to search for independent risk factors for postoperative complications. The RGB + LSG group (n = 46) had a mean age of 42 and a mean BMI of 44 kg/m(2). The indication for surgery was renewed weight gain or insufficient weight loss in 68 % of these cases. The LSG group (n = 259) had a mean age of 41 and a mean BMI of 49.2 kg/m(2). All procedures were performed laparoscopically. The complication rate was 8.6 % in the RGB + LSG group and 8 % in the SG group (p = 0.42). The fistula rates in the two groups were 4.3 and 3.4 %, respectively (p = 0.56), and the mean BMI at 2 years was 33.4 kg/m(2) (RGB + LSG group) and 34.4 kg/m(2), respectively (p = 0.83). The operating time for LSG (after subtracting the time associated with RGB for a combined procedure) averaged 107 min, whereas the operating time for front-line LSG was 89 min (p = 0.011). The propensity score analysis failed to find independent risk factors for postoperative complications. The performance of RGB + LSG is feasible and does not increase the postoperative morbidity rate. Weight loss after RGB + LSG validates the concept of "restrictive surgery after restrictive surgery". We did not find any independent risk factors that would have justified the avoidance of RGB + SG.

Ventral hernia repair in a potentially septic milieu

Repair of the abdominal wall is the last stage of abdominal surgery; pariet complications, particularly infection, can have serious impact on operative results. While abdominal wound infections are not universally preventable, they are often predictable; the aphorism of Jean Rives (Stoppa, 1999 [1]) summarizes this sequence: "Infection is the mother of postoperative incisional hernia and infection of the incisional hernia repair is the grand-daughter". Repair of the abdominal wall in a potentially septic milieu requires the solution of an equation involving four variables: mechanism of sepsis, its severity, the surgical approach, and choice of prosthetic material. These interdependent variables potentiate each other, requiring adaptations of surgical strategy that cannot be absolutely determined pre-operatively, even with collegial consultation.

Giant squamous cell carcinoma as a complication of a chronic enterocutaneous fistula: complex parietal reconstruction

Treatment of an enterocutaneous fistula is complex and may require multidisciplinary management, especially when associated with a neoplastic process. Here, we describe the case of a 59-year-old patient with a squamous cell carcinoma that had invaded the abdominal wall through a chronic enterocutaneous fistula identified 30 years ago. We combined parietectomy with small intestine and colon resection and inguinal lymphadenectomy in order to obtain clear surgical margins. At the same time, plastic surgery involved the implementation of a large bioprosthesis and coverage with a vastus lateralis muscle free flap.

Efficiency of laparoscopic sleeve gastrectomy on metabolic syndrome disorders: two years results

OBJECTIVES

There are very few studies evaluating the efficacy of sleeve gastrectomy on the metabolic syndrome, truly a worldwide pandemic. The main objective of this study was to retrospectively determine the evolution of the metabolic syndrome and its associated comorbidities (type 2 diabetes, arterial hypertension, and dyslipidemia) at 24 months after sleeve gastrectomy. The secondary objective was to determine the predictive factors for resolution of this syndrome.

MATERIAL AND METHODS

Between July 2004 and February 2008, 241 patients with morbid obesity (males: 17%) underwent sleeve gastrectomy in our center. Patients were seen in combined medical and surgical outpatient postoperative follow-up consultation at 3, 6, 12 and 24 months. Patients were classed as responders or not, according to whether or not the metabolic syndrome (as defined according to the National Cholesterol Education Program-Adult Treatment Panel III [NCEP-ATPIII]) disappeared at 24 months follow-up.

RESULTS

Thirty-six patients (15% of all patients, 30% of males) presented initially with metabolic syndrome. Twenty-six patients (72%) still had metabolic syndrome at 6 months, 17 patients (47%) at 12 months, and 13 patients (36%) at 24 months. The main parameters that regressed after sleeve gastrectomy were type 2 diabetes and hypertriglyceridemia. In univariate analysis, only one parameter (systolic blood pressure) appeared to be a factor of non-resolution of the metabolic syndrome at 24 months.

CONCLUSION

Our study showed that sleeve gastrectomy reduced the incidence of the metabolic syndrome and several of its components.

Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy?

Laparoscopic sleeve gastrectomy (LSG) has a specific morbidity profile in which gastric leak (GL) is the main complication. With a view to defining a standardized protocol for GL management, the present retrospective study sought to describe the clinical patterns of post-LSG GL and treatment of the latter in our university medical center. From July 2004 to December 2010, 25 patients were included. GL was described in terms of clinical presentation, time to onset, and location in the staple line. Treatment of GL with pharmacologic, radiologic, endoscopic, and/or surgical procedures was always validated by a multidisciplinary care team. "Treatment success" was defined as the absence of contrast agent leakage on CT and endoscopy after removal of covered metallic stent or pigtail drains. Systemic inflammation and peritonitis were the main signs for early-onset GL (56%), whereas pulmonary symptoms and intra-abdominal abscesses revealed delayed-onset GL (44%). Surgery was always performed for early-onset GL. In the total study population, the median number of endoscopic procedures was five (range, 1-11) per patient, of covered SEMS was three (range, 1-8), and of pigtail drains was three (range, 1-4). Nine (36%) patients presented endoscopic-related complications. Four (16%) patients with treatment failure underwent radical surgery. The mortality rate was 4% (n = 1). The management of post-LSG GL is challenging. Surgery was always performed for early-onset GL, whereas treatment of delayed-onset GL was based on endoscopy. Pigtail drains required fewer procedures per patient, were better tolerated, and had lower morbidity-mortality than covered SEMS.