Efficacit�� et s��curit�� de la sleeve gastrectomie chez les super-superob��ses

Aim

To assess the efficacy of laparoscopic sleeve gastrectomy for super-superobesity in 30 patients (BMI > 60 kg/m²).

Methods

This prospective study has analyzed the duration of surgery, length of hospital stay, post-operative complications, percentage of excess weight loss and need for a second surgery (re-sleeve gastrectomy or gastric bypass) in case of insufficient weight loss. Twenty-three women and 7 men were included, with a mean age of 35 years (18?C59), mean pre-operative BMI of 66 kg/m² (60?C85) and mean weight of 168 kg (140?C258). The study included one patient with complete situs inversus and 4 (14%) patients with a previous restrictive bariatric surgery.

Results

The mean duration of surgery was 120 minutes (80?C220). The mean hospital stay was 7.5 days (4?C28). There was no post-operative mortality. Laparotomy was not needed. There were 4 complications: sub-phrenic haematoma (2), gastric fistula (1) and pulmonary embolism (1). Out of the 23 patients who were followed up for 18 months, 17 (77%) patients achieved sufficient weight loss, whereas 6 (23%) patients showed insufficient weight loss, leading to re-sleeve gastrectomy (in 3 cases) or gastric bypass (in 2 cases), and one patient refused another surgery. Three years after the initial sleeve gastrectomy, the mean weight loss was 56 kg (28?C144), the mean percentage of excess weight loss was 51% (28?C82) and the mean loss of BMI was 20 kg/m² (10?C39).

Conclusion

These results show that laparoscopic sleeve gastrectomy can be performed safely, with few post-operative complications and is efficient in treating super-superobese patients. It can be either a stand-alone procedure if the results are good or a first-stage procedure before a re-sleeve or a gastric bypass if long-term results are insufficient.     

Chirurgie de l’incontinence urinaire à l’effort chez la femme obèse

Obesity is an established risk factor for SUI. Among overweight women, a weight loss program improves urinary incontinence with a reduction in the frequency of self-reported urinary incontinence episodes and may be suggested as a first-line therapy. Success rates after TVT are similar among obese patients and normal-weight patients, and TVT is the prime procedure to treat SUI in obese patients. Obesity does not appear as a risk factor for intra- and postoperative complications.     

Aspects diagnostiques et th��rapeutiques de la polypose de Peutz-Jeghers chez l��enfant

Aim

To describe the diagnostic circumstances, outcome and management of Peutz-Jeghers polyposis in children.

Methods

Retrospective analysis of 25 cases. Diagnosis of at least one hamartomatous polyp associated with 2 of the 3 following criteria: family history, mucocutaneous pigmentation, small bowel polyps and/or STK11 gene mutation identification.

Results

Diagnosis based upon clinical criteria 21 times, median age of 8.2 years, by revealing acute intestinal intussusception (II) in 13 cases (2.8 to 15.1 years). Genetic analysis was positive in 16/18 cases. During follow-up (median 4.6 years), 15 children had an II. Sixty upper gastrointestinal endoscopies and 51 colonoscopies revealed polyps in 85% and 80% of cases, with polypectomy in 62% and 70%. Twenty-one video-capsule endoscopies revealed bowel polyps 18 times. Seven children had double-balloon endoscopy with polypectomy. Eighteen patients underwent 29 surgeries with intra-operative enteroscopy 12 times and bowel resection 18 times.

Comments

The risk of II and resection is high and early. Management by systematic endoscopic examination could reduce this risk. A prospective study will only validate the recommended age to start this endoscopy survey.     

Intérêt pronostique du dosage de la procalcitonine pour la prédiction du risque de fistule post gastrectomie par manchon type Sleeve chez des patients obèses

Introduction

Obesity is an epidemiologic major disease of our modern societies. Sleeve gastrectomy is one of the main procedures of baritatric surgery. Staple line fistula is the main risk of complications after Sleeve gastrectomy. No clinical or biological data can predict appearance of fistula. Dosage of procalcitonin is a very sensible and specific marker of post operative sepsis.

Methods

A monocentric and prospective study was performed in Centre Hospitalier Intercommunal du Bassin de Thau. We studied tachycardia, white blood cells counts, CRP and procalcitonin at D3 and D5.

Results

We included 105 consecutive patients. Two of them developed a fistula (1.9%), 4 of them a bleeding (3.8%). Positives predictives values of hyperleucocytosis, tachycardia, CRP levels at D3 were respectively 15.3%, 5%, 11.1%. Negatives predictives values of those datas were 100%, 100% and 100%. At D5, positives predictives values of hyperleucocytosis, tachycardia, CRP levels were respectively 20%, 12.5%, 8%. Negatives predicitves values of those datas were 100%, 98.9%, and 100%. Positive predictive value of procalcitonin at D3 and D5 were 100%, as well as negative predictive value.

Conclusion

Procalcitonin is a very interesting marker to predict fistula after Sleeve gastrectomy. These results need to be validated by larger studies. The 2 fistulas arose in patients who had a lap band removed.     

Le dialogue intestin, tissu adipeux et hypothalamus influence l’obésité et le diabète de type 2

The brain, and more particularly the hypothalamus, is an integrative center for numerous signals from various origins implicated in the control of satiety and energy metabolism. Peripheral tissues (gut, adipose tissue) are able to send endocrine and/or nervous messages to the hypothalamus which, in turn controls food intake and peripheral glucose utilization. Then, the generation of an abnormal peripheral message and/or the arrival of aberrant information directly in the hypothalamus could be involved in the settlement of metabolic disorders (obesity and type 2 diabetes). In addition to peripheral disorders related to such diseases, it becomes of crucial importance to address these major “hypothalamic disorders” by acting, when possible, directly on hypothalamic targets or instead targeting molecular, cellular and tissue actors known to be in close communication with the hypothalamus. Therefore, the treatment of metabolic disorders needs a global vision of the body through the inter-organ communication, and the central nervous system behaving as an integrative center.     

Intolérance à l’effort de la personne obèse : modalités d’évaluation et conséquences pour la prescription de l’activité physique

Physical activity is an important modality in the treatment of obesity. However, obesity is often associated with exercise intolerance. The aim of this didactic article is to clarify respiratory, cardiovascular, metabolic and musculoskeletal factors that contribute to exercise intolerance in obese individuals. Evaluation modalities will also be presented, in order to individualize adapted physical activities to this population.     

Dysfonctions du système nerveux sympathique et de la signalisation catécholaminergique chez l’obèse

The sympathetic nervous system (SNS) has an essential role in the maintenance of metabolic, gastrointestinal and cardiovascular homeostasis. Activation of SNS involves noradrenaline release by noradrenergic fibers and adrenaline secretion by adrenal medulla. The SNS has a major role in the control of adipose tissue function both directly, on adipocytes and adipose tissue vessels, and due to effects on pancreatic hormones secretion. Although a number of previous findings on SNS activity evaluation in humans provided inconsistent findings, various alterations of SNS effects on metabolism have been now implicated in the development and the maintenance of obesity. SNS activity to the skeletal muscle, evaluated via muscle sympathetic nerve activity (MSNA), is related to early renal, cardiac and endothelial dysfunctions in the obese. Reduced SNS activity has been claimed to represent a risk factor for weight gain. However, elevated SNS activity is present in obesity. Increased baseline SNS activity and blunted SNS-mediated thermogenic response to a meal may play a role in the progression of obesity related metabolic and cardiovascular diseases. Alterations of fat cell adrenergic receptor-mediated responses have been reported in the obese; they suggest an adaptation of adipose tissue to the level of SNS activity. This review provides an overview of physiological aspects of the SNS involvement in normal and obese subjects. Physiological and pathological changes in SNS activity are summarized. Modifications occurring in adipose tissue function and fat cell responsiveness to noradrenaline and adrenaline are also considered.     

Attentes des patients et des professionnels vis-à-vis d’un site Internet dédié à l’obésité

The objective of this survey was to collect expectations of patients (via a questionnaire and focus group) and health professionals (via a questionnaire) concerning the development of a regional website on obesity. Most patients and health professionals expressed an interest to the creation of such web site with certain common expectations (advices, medical and practical information) and others specific to patients (supportive care, coaching and exchanges with health professionals and other patients) and health professionals (training and tools).     

Rôle du niveau verbal sur l’expression et l’évaluation de la douleur chez des sujets déficients intellectuels

Résumé Objectif  les études portant sur l’évaluation de la douleur chez les sujets déficients intellectuels concernent surtout la déficience profonde ou sévère. De fait, la littérature met en avant leur incapacité à utiliser les outils d’autoévaluation. Ce travail étudie l’expression verbale et l’évaluation de douleurs rapportées chez des sujets déficients intellectuels légers et moyens et le r?le du niveau verbal. Sujets et méthode  quatorze sujets atteints de déficience intellectuelle moyenne et légère, sans aucune atteinte physique agés de 8 à 18 ans (moyenne d’age 15 ans). A l’aide de l’EVA et de l’échelle des visages, ils ont évalué l’intensité douloureuse du personnage d’une vignette ou celle d’une douleur rapportée. Ils ont ensuite décrit ces douleurs. Résultats  les sujets déficients intellectuels de notre étude manifestent des capacités d’expression et d’évaluation de la douleur. Ils sont en mesure d’utiliser des outils d’autoévaluation pour estimer la douleur d’un personnage représenté sur une image ou bien une douleur rapportée. Conclusion  la présence de compétences à exprimer verbalement la douleur chez des sujets porteurs d’atteintes intellectuelles indique que ces compétences ne dépendent pas du niveau de développement de la pensée conceptuelle. Nous nous orientons désormais vers l’étude de la dynamique du dialogue entre le sujet et la personne chargée d’évaluer sa douleur.      

Représentations des médicaments et expérience de la douleur chez des patients souffrant du syndrome de fibromyalgie

Aim

The purpose of this article is to analyse the representations and categorisations of medication constructed by patients with a fibromyalgia syndrome.

Materials and methods

Thirty-five semi-structured interviews were realised with patients. They were analysed according to thematic analysis.

Results

Medicines and pain are co-constructed in the patients’ discourses. Medicines are evaluated and categorised by patients by analogy with pain and its paradoxical representations in the body. Four axes structuring this analogy have been identified: space (local/diffuse), time (permanent/sudden), intensity (soft/hard) and familiarity (usual/new).

Conclusion

To analyse patients’ representations is a way to adjust patient-doctor communication about medicines.     

Modification durable des habitudes de vie par l’activité physique dans la lutte contre l’obésité chez l’adulte : présentation du protocole de faisabilité

A multidisciplinary plan to fight against adult obesity by physical activity/exercises, based on published scientific data, was implemented within a nonprofit organization. The first four years were dedicated to lead a feasibility study with 154 persons who joined the program. The aim of this intervention is the lasting change of lifestyle. This study allowed us to define a range of indicators to measure its benefits. The purpose of this article is to present the feasibility study protocol as well as the evaluation of its health benefits.     

Syndrome de restauration immunitaire chez les patients infectés par le virus de l’immunodéficience humaine et traités par antirétroviraux

Early antiretroviral therapy (ART) for Human Immunodeficiency Virus (HIV) infected people has led to a decrease in the risk of mortality and in the occurrence of opportunistic infections (OI). However, a non negligible proportion of patients will develop unusual and exaggerated inflammatory response to opportunistic pathogens named immune reconstitution inflammatory syndrome (IRIS). Paradoxical IRIS occurs in patients already efficiently treated for an OI, and who deteriorate after initiation of ART while unmasking IRIS occurs in patients who have already initiated ART and in whom a latent OI exists before ART initiation. IRIS requires the exclusion of any new OI, uncontrolled OI, and drug toxicity. IRIS is estimated to occur in 16% of the patients, with a low mortality, except for central nervous system IRIS. Risk factors for IRIS are advanced HIV infection, disseminated OI, early ART introduction after OI treatment, as well as rapid immune and viral response to ART. IRIS pathophysiology leading to excessive immune response is not well understood. Clinical manifestations of IRIS are diverse and related to the involved pathogen. Mycobacteria, cryptococcus, cytomegalovirus and JC virus are the main agents responsible for IRIS. IRIS treatment is not well established. Except for life-threatening IRIS, ART should not be discontinued. Steroids can be used for severe IRIS associated with tuberculosis and progressive multifocal leukoencephalopathy.     

Utilisation des filtres échangeurs de chaleur et d’humidité au cours de la ventilation mécanique des patients de réanimation

Adequate heating and humidifying of inspired gases is required for long-term mechanical ventilation of intensive care unit (ICU) patients. This process can be achieved by either a heated humidifier or by more recent disposable devices called heat and moisture exchangers (HME). The choice to use one method instead of the other depends on both technical and economic considerations. HMEs are more often used nowadays because they are simple to use and cost-effective. Their performances are for several models comparable to those of a heated humidifier. The vast majority of ICU patients can be ventilated with an HME. They are usually changed after 24 h of use. It has recently been shown that some HMEs can be changed only every 48 h and that at least one HME can be changed only once a week in some patients. Using HMEs instead of heated humidifiers has no clear impact on the rate of nosocomial pneumonia but considerably reduces the cost of mechanical ventilation and the number of septic procedures, thus improving quality of care.