Obesity, sleeve gastrectomy and gastro-esophageal reflux disease

Sleeve gastrectomy (SG) is the most frequently performed operation for morbid obesity in the world. In spite of its demonstrated efficacy, the Achilles' Heel of this procedure seems to be either pre-existing or de novo gastro-esophageal reflux disease (GERD) with its potential complications such as peptic esophagitis, Barrett's esophagus and, in the long-term, esophageal adenocarcinoma. According to factual literature, it appears clear that Roux-en-Y gastric bypass is the preferred choice in case of pre-existing GERD or hiatal hernia discovered during preoperative workup for bariatric surgery. Nonetheless, certain authors propose performance of SG with an associated antireflux procedure such as Nissen fundoplication. Strict endoscopic surveillance is recommended after bariatric surgery. Revisional surgery (conversion of SG into Roux-en-Y gastric bypass (RYGB)) is the treatment of choice for patients who develop GERD after SG when conservative treatment (modified lifestyle and proton pump inhibitors) has failed. Lastly, with regard to the risk of esophageal adenocarcinoma after SG, large scale studies with adequate follow-up are necessary to come to factual conclusions. In all cases, the management of this conundrum remains a major technical challenge that has to be taken in consideration in future years, especially because of the current expansion of bariatric surgery.

Conceptual innovation: 4P Medicine and 4P surgery

The aim of this article is to present the concept of "4P medicine" i.e., medicine that is Personalized, Preventive, Predictive, and Participatory. We will discuss the evolution from cure-focused traditional medicine toward personalized medicine based on genome analysis. This new approach is illustrated by several clinical examples such as prevention of cardiovascular diseases (primary and secondary), prophylactic cancer surgery, targeted therapies, targeted peri-operative care and patient participation in their care. Finally, it will discuss the impact of this development on the health system of the future and the ethical questions raised by this new approach.

Evidence-based evaluation of abdominal drainage in pancreatic surgery

Pancreatic fistula is the most common and dreaded complication after pancreatic resection, responsible for high morbidity and mortality (2 to 30%). Prophylactic drainage of the operative site is usually put in place to decrease and/or detect postoperative pancreatic fistula (POPF) early. However, this policy is currently debated and the data from the literature are unclear. The goal of this update is to analyze the most recent evidence-based data with regard to prophylactic abdominal drainage after pancreatic resection (pancreatoduodenectomy [PD] or distal pancreatectomy [PD]). This systematic review of the literature between 1990 and 2020 sought to answer the following questions: should drainage of the operative site after pancreatectomy be routine or adapted to the risk of POPF? If a drainage is used, how long should it remain in the abdomen, what criteria should be used to decide to remove it, and what type of drainage should be preferred? Has the introduction of laparoscopy changed our practice? The literature seems to indicate that it is not possible to recommend the omission of routine drainage after pancreatic resection. By contrast, an approach based on the risk of POPF using the fistula risk score seems beneficial. When a drain is placed, early removal (within 5 days) seems feasible based on clinical, laboratory (C-reactive protein, leukocyte count, neutrophile/lymphocyte ratio, dosage and dynamic of amylase in the drains on D1, D3±D5) and radiological findings. This is in line with the development of enhanced recovery programs after pancreatic surgery. Finally, this literature review did not find any specific data relative to mini-invasive pancreatic surgery.

Is an enhanced recovery program (ERP) after rectal surgery as feasible as after colonic surgery? A multicentre Francophone study of 870 rectal resections

BACKGROUND

Enhanced recovery program (ERP) is well-established in colorectal surgery. Rectal surgery (RS) is known to be associated with high morbidity and prolonged hospital stay, which might explain why ERPs are less applied in this specific group of patients. The aim of this large-scale study was to assess the feasibility of an ERP in RS compared with colonic surgery.

METHODS

This study was a retrospective analysis of a prospective database including 3740 patients eligible for colorectal resection from February 2014 to January 2017 in 75 European Francophone centres. Patients were divided into two groups (colon group C vs. rectum group R). The main endpoint was compliance with ERP components. A subgroup analysis was performed in patients for whom a defunctioning stoma (DS) was required after RS.

RESULTS

A total of 3740 patients were included. There were 2870 patients in group C and 870 patients in group R. The overall compliance rate for ERPs was 81.71% in group C and 79.09% in group R. Patients were significantly less mobilized within 24 h in group R. Specific recommendations for RS concerning bowel preparation and abdominal drainage were significantly less implemented. Overall morbidity was significantly higher in group R. Mean length of stay (LOS) was significantly shorter in group C. In the sub-group analysis, a DS was significantly associated with fewer compliance with early mobilization and early feeding, leading to significantly longer LOS (group R).

CONCLUSION

ERP is safe and effective in RS, despite the well-known higher morbidity and LOS compared with colonic surgery. DS could be a limiting factor in ERP implementation after RS.

Risks of viral contamination in healthcare professionals during laparoscopy in the Covid-19 pandemic

The Covid-19 pandemic has markedly changed our practices. This article analyses the risks of contamination among healthcare professionals (HCPs) during laparoscopic surgery on patients with Covid-19. Harmful effects of aerosols from a pneumoperitoneum, with the virus present, have not yet been quantified. Measures for the protection of HCPs are an extrapolation of those taken during other epidemics. They must still be mandatory to minimise the risk of viral contamination. Protection measures include personal protection equipment for HCPs, adaptation of surgical technique (method for obtaining pneumoperitoneum, filters, preferred intracorporeal anastomosis, precautions during the exsufflation of the pneumoperitoneum), and organisation of the operating room.

Large-scale implementation of enhanced recovery programs after surgery. A francophone experience

INTRODUCTION

Enhanced recovery after surgery program (ERP) has now surpassed the stage of clinical research in certain specialties and currently poses the problematic of large-scale implementation. The goal of this study was to report the experience during the first year of implementation in three French-speaking countries.

MATERIAL AND METHODS

This is a prospective study in which 67 healthcare centers, all registered in the Grace-Audit databank, participated. Included were patients undergoing colorectal (CRS), bariatric (BS) and orthopedic hip and knee surgery (OS), performed within an ERP. The main endpoints were duration of hospital stay, postoperative morbidity, the degree of compliance with the elements of the ERP, the relation between the extent of application of the elements and postoperative hospital stay, and finally the completeness of data inclusions in the databank.

RESULTS

A total of 1904 patients were included in the Grace-Audit databank between January 1, 2015 and January 31, 2016, undergoing CRS (n=490), BS (n=431), and OS (n=983). The mean implementation rate was 83.7±10.0% for CRS, 75.0±23.7% for BS, and 83.5±14.9% for OS. The duration of hospital stay was 6.5 days for CRS, 2.6 days for BS and 3.4 days for OS. Overall postoperative morbidity (onset of postoperative undesirable event), surgical morbidity (superficial or deep organ space surgical site complications such as bleeding, infection or defective healing) and readmission rates were 20.6%, 7.5%, and 5.7% for CRS; 2.5%, 1.4%, and 1.6% for BS and 2.9%, 0.2%, and 2% for OS, respectively. A statistically significant relationship was found between the degree of compliance of the elements of ERP and the duration of hospital stay for CRS and BS; hospital stay was reduced when at least 15 of the 22 elements of the program were applied (P<0.001). The patients included in the Grace-Audit databank represented less than 20% of the patients undergoing operation in the same establishments during the study period for all three specialties.

CONCLUSIONS

This study shows that large-scale ERPs are feasible and safe in French-speaking countries. Nonetheless, although encouraging, these preliminary results highlight that implementation must be improved in specialties such as bariatric surgery and that more complete data collection is needed.

Patients' willingness to drink carbohydrate liquids two hours before surgery

Carbohydrate loading is an important component of enhanced recovery pathways. Some practitioners argue that patients' low acceptance for drinking such solutions could hamper the implementation of a full protocol. The aim of this study was to assess patients' actual acceptance of drinking carbohydrate solutions. Thirty patients scheduled to undergo digestive surgery participated in a survey which asked them to evaluate the taste of a carbohydrate loading drink mix (Clinutren Preload). They were asked whether they took all the solution, experienced nausea or vomiting, and whether they would be willing to take the solution again. Twenty two patients (73%) took all the solution, 27 (90%) judged the solution easy or quite easy to drink, 25 (83%) found the taste good or quite good, and 23 experienced (76%) no nausea. Finally 16 patients (54%) responded that they would be willing to take it again if indicated. We concluded that patient-related factors were not sufficient to hamper the implementation of carbohydrate loading before major surgery. The lack of implementation is probably related more to the attitude of the practitioner.