The place of upper gastrointestinal tract endoscopy before and after vertical banded gastroplasty for morbid obesity

In industrialized countries, surgical gastroplasty is performed more and more frequently in patients with morbid obesity. The aims of this prospective study were to determine the incidence of upper gastrointestinal lesions in obese patients and to assess the place of digestive endoscopy in symptomatic patients after gastroplasty. A consecutive group of 159 obese patients were studied before and after vertical banded gastroplasty. In the preoperative evaluation, reflux esophagitis and gastroduodenal lesions were endoscopically observed in 31% and 37% of the patients, respectively. Interestingly, the majority of the obese patients with upper gastrointestinal lesions were asymptomatic. In the postoperative follow-up period, 55 of the 159 patients complained of upper gastrointestinal symptoms such as vomiting (72%), esophageal reflux (17%), and epigastric pain (3%). Stenosis of the outlet of the gastric pouch was described in 40 of the 55 symptomatic patients. Esophagitis was observed in 60% of these patients. Endoscopic dilation using Savary bougies or TTS balloon was successfully performed in all the patients with symptomatic stenosis of the gastric outlet. Food impaction was endoscopically removed in four patients. Thus, we recommend performing an upper gastrointestinal endoscopy in obese patients who are candidates for surgical gastroplasty because of the high incidence of upper gastrointestinal peptic lesions. Endoscopy is also helpful in patients with digestive disorders occurring after gastroplasty in order to define and to treat the lesions.

[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.

Efficient retroviral-mediated gene transfer into primary culture of murine and human hepatocytes: expression of the LDL receptor

The ex vivo approach to hepatic gene therapy involves several steps, which include the isolation and culture of hepatocytes, followed by their transduction with a retrovirus. Subsequently, autologous hepatocytes are transplanted. The number of hepatocytes that can be transduced by retroviruses bearing the therapeutic gene is one of the limiting steps that can impair the success of this strategy. We presently describe an experimental approach that leads to improved transduction efficiency in mouse and human hepatocytes in vitro. By using a recombinant retrovirus bearing the Escherichia coli beta-galactosidase gene, we show that addition of growth factors to the cells, namely human hepatocyte growth factor (HGF), allows marked increase in the transduction efficiency in mouse (up to 80%) and human (40%) hepatocytes. Familial hypercholesterolemia (FH) is due to mutation in the low-density lipoprotein (LDL) receptor gene and results in a deficiency in LDL receptors. Transduction of the human LDL receptor cDNA under the transcriptional control of the L-type pyruvate kinase promoter-activator into mouse hepatocytes led to an elevated tissue-specific expression of the human protein. These results suggest that the ex vivo approach remains a promising alternative for hepatic gene therapy.

Elbow arteriovenous fistulas for chronic haemodialysis

Arteriovenous fistulas (AVFs) were created at the elbow, rather than using prosthetic grafts, when forearm vessels were inadequate. A total of 272 such fistulas were constructed: 49 between the brachial artery and a forearm vein, 91 between the brachial artery and the elbow perforating vein, 52 between the brachial artery and the cephalic vein and 80 between the brachial artery and the basilic vein. In each case the vein was sutured end to side to the artery. The immediate failure rate was 11.8 per cent. The 1- and 4-year cumulative patency rates were 68.7 and 51.2 per cent for brachial artery-forearm vein AVFs, 80.3 and 68.0 per cent for those between the brachial artery and the elbow perforator, 74.1 and 61.3 per cent for brachial artery-cephalic vein fistulas, and 76.7 and 49.2 per cent for those between the brachial artery and the basilic vein. The elbow AVF is a reliable means of establishing vascular access for haemodialysis.

Role of surgical therapy in management of intractable ascites

Almost 10% of patients with cirrhosis and ascites develop intractable ascites. When large-volume paracentesis fails to relieve ascites, patients may be submitted to one of the three following surgical options: portosystemic shunting, peritoneovenous shunting, or liver transplantation. Portosystemic shunting is efficient in clearing ascites, but it is associated with a high rate of encephalopathy and liver failure. The indications for portosystemic shunting are therefore limited for treatment of intractable ascites and should be performed only in patients with good liver function in whom all other treatments failed. Peritoneovenous shunting has been associated with a high rate of early complications and valve obstruction. Improvements in perioperative care and in the material used have greatly reduced the operative risks and increased the patency rate. Mortality remains high in patients with severe liver failure or with a history of spontaneous bacterial peritonitis or variceal bleeding. Peritoneovenous shunting should not be done when these risk factors are present. In the absence of such risk factors, peritoneovenous shunting is a good procedure and may provide definitive relief of ascites and long-term survival in more than 50% of the operated patients. In patients with poor risk factors liver transplantation may be preferable, and the onset of intractable ascites in a patient with a severely compromised liver should trigger the indication of liver replacement.

[Peri-colostomy hemorrhage due to portal hypertension secondary to hepatic metastasis of a rectal adenocarcinoma. Apropos of a case report. Literature review]

The authors present a case report of recurrent peristomal variceal bleeding resulting from portal hypertension induced by hepatic metastases of a rectal cancer. They propose mucocutaneous disconnection as a simple and effective palliative surgery in order to prevent new bleeding. Discussion is based on a review of the literature and illustrates the different therapeutic options for this complication.

[One-stage subtotal colectomy in the emergency treatment of occlusive left colonic neoplasms]

The authors present a series of 17 emergency subtotal colectomies as treatment of malignant occlusions of the left colon. They insist on the advantages of this operation as well as for the short term results (morbidity, mortality) and for the rare functional disease (diarrhea).