Updates on gastric electrical stimulation to treat obesity: Systematic review and future perspectives

AIM: To evaluate the current state-of-the-art of gastric electrical stimulation to treat obesity. METHODS: Systematic reviews of all studies have been conducted to evaluate the effect of different types of gastric electrical stimulation(GES) on obesity.RESULTS: Thirty-one studies consisting of a total of 33 different trials were included in the systematic review for data analysis. Weight loss was achieved in most studies, especially during the first 12 mo, but only very few studies had a follow-up period longer than 1 year. Among those that had a longer follow-up period, many were from the Transcend(Implantable Gastric Stimulation) device group and maintained significant weight loss. Other significant results included changes in appetite/satiety, gastric emptying rate, blood pressure and neurohormone levels or biochemical markers such as ghrelin or HbA1 c respectively. CONCLUSION: GES holds great promises to be an effective obesity treatment. However, stronger evidence is required through more studies with a standardized way of carrying out trials and reporting outcomes, to determine the long-term effect of GES on obesity.

Short-term and middle-term evaluation of laparoscopic hepatectomies compared with open hepatectomies: A propensity score matching analysis

AIM To compare short-term results between laparoscopic hepatectomy and open hepatectomy using a propensity score matching. METHODS A patient in the laparoscopic liver resection(LLR) groupwas randomly matched with another patient in the open liver resection(OLR) group using a 1:1 allocated ratio with the nearest estimated propensity score. Patients of the LLR group without matches were excluded. Matching criteria included age, gender, body mass index, American Society of Anesthesiologists score, potential co-morbidities, hepatopathies, size and number of nodules, preoperative chemotherapy, minor or major liver re-sections. Intraoperative and postoperative data were compared in both groups.RESULTS From January 2012 to January 2015, a total of 241 hepa-tectomies were consecutively performed, of which 169 in the OLR group(70.1%) and 72 in the LLR group(29.9%). The conversion rate was 9.7%(n = 7). The mortality rate was 4.2% in the OLR group and 0% in the LLR group. Prior to and after propensity score matching, there was a statistically significant difference favorable to the LLR group regarding shorter operative times(185 min vs 247.5 min; P = 0.002), less blood loss(100 m L vs 300 m L; P = 0.002), a shorter hospital stay(7 d vs 9 d; P = 0.004), and a significantly lower rate of medical complications(4.3% vs 26.4%; P < 0.001). CONCLUSION Laparoscopic liver resections seem to yield better short-term and mid-term results as compared to open hepatectomies and could well be considered a privileged approach and become the gold standard in carefully selected patients.

Diagnosis and Therapeutic Management of Parathyroid Cysts

Objectives: The parathyroid cysts (PCs) are rare and their diagnosis and therapeutic management are not clearly established. The aim of the study was to evaluate the characteristics of parathyroid cysts. Methods and Materials: Twenty-five patients with PC were included in this retrospective study. The PCs were discovered as follows: cervical mass (n = 18), screening for other pathologies (n = 7). Intracystic parathyroid hormone determination was performed in 6 cases. Results: Eight patients presented an hyperparathyroidism. Mean cyst size was 21.1 mm (ext 4 - 70 mm) by 19.8mm (5 - 45 mm). Twenty four cysts were cervical (resection by cervicotomy), and one was mediastinal (resection by sternotomy). In addition to the resection of the PC, 3 adenomas, 1 hyperplasia of the parathyroid glands, 14 benign thyroid diseases and 4 papillary carcinomas were recognized and treated during the cervicotomies. Conclusion: The diagnosis of PC is uncommon and must be based primarily on the study of the cyst liquid obtained by percutaneous puncture (intracystic parathyroid hormone measurement). True PCs are non functional.

Can we talk about “futile surgery” for the upfront treatment of the perihilar cholangiocarcinoma?

In this work(1),Ratti et al.tries to identify a subgroup of patients with perihilar cholangiocarcinoma(PHC)for whom the benefit of surgery could be compromised by morbidity,mortality and the risk of early tumor recurrence.Data for this study come from a multi-institutional database that includes consecutive patients undergoing elective surgery for PHC in 27 Western centers(with experience of more than 15 major liver resections per year)starting in January 2000.Data from 2,271 patients were analyzed retrospectively.As there is neither international consensus on preoperative management nor standardization of surgical technique,the indications for resection were validated at a local multidisciplinary consultation meeting.Preoperative optimization was standardized with endoscopic or percutaneous biliary drainage to treat jaundice and the performance of portal embolization was proposed in the event of insufficient volume of the future remaining liver.

Vascular complications following liver transplantation:Aliterature review of advances in 2015

Although vascular complications(VCs) following orthotopic liver transplantation(OLT) seldom occur, they are the most feared complications with a high incidence of both graft loss and mortality, as they compromise the blood flow of the transplant(either inflow or outflow). Diagnosis and therapeutic management of VCs constitute a major challenge in terms of increasing the success rate of liver transplantation. While surgical treatment used to be considered the first choice for management, advances in endovascular intervention have increased to make this a viable therapeutic option. Considering VC as a rare but a major and dreadful issue in OLT history, and in view of the continuing and rapid progress in recent years, an update on these uncommon conditions seemed necessary. In this sense, this review comprehensively discusses the important features(epidemiological, clinical, paraclinical, prognostic and therapeutic) of VCs following OLT.

Fluorescent cholangiography: An up-to-date overview twelve years after the first clinical application

Laparoscopic cholecystectomy(LC)is one of the most frequently performed gastrointestinal surgeries worldwide.Bile duct injury(BDI)represents the most serious complication of LC,with an incidence of 0.3%-0.7%,resulting in significant perioperative morbidity and mortality,impaired quality of life,and high rates of subsequent medico-legal litigation.In most cases,the primary cause of BDI is the misinterpretation of biliary anatomy,leading to unexpected biliary lesions.Near-infrared fluorescent cholangiography is widely spreading in clinical practice to delineate biliary anatomy during LC in elective and emergency settings.The primary aim of this article was to perform an up-to-date overview of the evolution of this method 12 years after the first clinical application in 2009 and to highlight all advantages and current limitations according to the available scientific evidence.

Management of biliary complications after liver transplantation

Biliary complications(BC) currently represent a major source of morbidity after liver transplantation. Although refinements in surgical technique and medical therapy have had a positive influence on the reduction of postoperative morbidity, BC affect 5% to 25% of transplanted patients. Bile leak and anastomotic strictures represent the most common complications. Nowadays, a multidisciplinary approach is required to manage such complications in order to prevent liver failure and retransplantation.

Chronic pancreatitis:A surgical disease?Role of the Frey procedure

Although medical treatment and endoscopic interven-tions are primarily offered to patients with chronic pancreatitis, approximately 40% to 75% will ultimately require surgery during the course of their disease. Al-though pancreaticoduodenectomy has been considered the standard surgical procedure because of its favorable results on pain control, its high postoperative complica-tion and pancreatic exocrine or/and endocrine dysfunc-tion rates have led to a growing enthusiasm for duodenal preserving pancreatic head resection. The aim of this review is to better understand the rationale underlying of the Frey procedure in chronic pancreatitis and to ana-lyze its outcome. Because of its hybrid nature, combin-ing both resection and drainage, the Frey procedure has been conceptualized based on the pathophysiology of chronic pancreatitis. The short and long-term outcome, especially pain relief and quality of life, are better after the Frey procedure than after any other surgical proce-dure performed for chronic pancreatitis.

Transgastric cholecystectomy:From the laboratory to clinical implementation

After the first report by Kalloo et al on transgastric peritoneoscopy in pigs,it rapidly became apparent that there was no room for an under-evaluated concept and blind adoption of an appealing(r)evolution in minimal access surgery.Systematic experimental work became mandatory before any trans lation to the clinical setting.Choice and management of the access site,techniques of dissection,exposure,retraction and tissue approximationsealing were the basics that needed to be evaluated before considering any surgical procedure or study of the relevance of natural orifice transluminal endoscopic surgery(NOTES).After several years of testing in experimental labs,the revolutionary concept of NOTES,is now progressively being experimented on in clinical settings.In this paper the authors analyse the challenges,limitations and solutions to assess how to move from the lab to clinical implementation of transg astric endoscopic cholecystectomy.

Impact of previous cyst-enterostomy on patients' outcome following resection of bile duct cysts

AIM:To analyze the impact of previous cyst-enterostomy of patients underwent congenital bile duct cysts(BDC)resection.METHODS:A multicenter European retrospective study between 1974 and 2011 were conducted by the French Surgical Association.Only Todani subtypes I and IVb were included.Diagnostic imaging studies and operative and pathology reports underwent central revision.Patients with and without a previous history of cystenterostomy(CE)were compared.RESULTS:Among 243 patients with Todani types I and IVb BDC,16 had undergone previous CE(6.5%).Patients with a prior history of CE experienced a greater incidence of preoperative cholangitis(75%vs 22.9%,P<0.0001),had more complicated presentations(75%vs 40.5%,P=0.007),and were more likely to have synchronous biliary cancer(31.3%vs 6.2%,P=0.004)than patients without a prior CE.Overall morbidity(75%vs 33.5%;P<0.0008),severe complications(43.8%vs 11.9%;P=0.0026)and reoperation rates(37.5%vs 8.8%;P=0.0032)were also significantly greater in patients with previous CE,and their Mayo Risk Score,during a median follow-up of 37.5 mo(range:4-372 mo)indicated significantly more patients with fair and poor results(46.1%vs 15.6%;P=0.0136).CONCLUSION:This is the large series to show that previous CE is associated with poorer short-and longterm results after Todani types I and IVb BDC resection.

Which method of distal pancreatectomy is cost-effective among open,laparoscopic,or robotic surgery?

Background: The aim of this study was to analyze the clinical and economic impact of robotic distal pancreatectomy, laparoscopic distal pancreatectomy, and open distal pancreatectomy. Methods: All consecutive patients who underwent distal pancreatic resection for benign and malignant diseases between January 2012 and December 2015 were prospectively included. Cost analysis was performed;all charges from patient admission to discharge were considered. Results: There were 21 robotic (RDP), 25 laparoscopic (LDP), and 43 open (ODP) procedures. Operative time was longer in the RDP group (RDP =345 minutes, LDP =306 min, ODP =251 min, P=0.01). Blood loss was higher in the ODP group (RDP =192 mL, LDP =356 mL, ODP =573 mL, P=0.0002). Spleen preservation was more frequent in the RDP group (RDP =66.6%, LDP =61.9%, ODP =9.3%, P=0.001). The rate of patients with Clavien-Dindo > grade III was higher in the ODP group (RDP =0%, LDP =12%, ODP =23%, P=0.01), especially for non-surgical complications, which were more frequent in the ODP group (RDP =9.5%, LDP =24%, ODP =41.8%, P=0.02). Length of hospital stay was increased in the ODP group (ODP =19 days, LDP =13 days, RDP =11 days, P=0.007). The total cost of the procedure, including the surgical procedure and postoperative course was higher in the ODP group (ODP =30,929 Euros, LDP=22,150 Euros, RDP =21,219 Euros, P=0.02). Conclusions: Cost-effective results of RDP seem to be similar to LDP with some better short-term outcomes.

Interpatient heterogeneity in hepatic microvascular blood flow during vascular inflow occlusion (Pringle manoeuvre)

Hepatic inflow occlusion(Pringle manoeuvre),is a widely used technique,consisting in temporary intermittent or continuous clamping of the hepatic pedicle.This technique was described in 1908 by Pringle to minimize blood loss during emergency surgery for liver trauma.Therefore,in hepatobiliary surgery,the Pringle manoeuvre assumes a primary role especially in complex liver resections where an intraoperative blood loss could be significant.Afterwards.

Comment on:simultaneous versus delayed resection for initially resectable synchronous colorectal cancer liver metastases

We read with great interest the recently published article of Boudjema and collaborators(1).The authors evaluated the safety and efficacy of delayed resection(DR)versus simultaneous resection(SR)for patients with initially resectable synchronous colorectal cancer liver metastases(CRC-SLM).The aforementioned study(METASYNC)was the first randomized controlled trial comparing two resection strategies for CRC-SLM.In the literature,large retrospective studies didn’t seem to favor one type of treatment,particularly when comparisons are based on a propensity match score(2).

Value-based healthcare:a novel approach to the evaluation of patient care

Patti et al.(1)have reported an analysis of the literature searching for an evaluation of robotic liver and pancreatic surgery according to a value-based health care(VBHC)approach.This model was developed by Porter(2)in order to consider the following two aspects:vthe outcomes that matter most to patients,which are defined as the sum of patients’health objectives;vthe costs required to achieve these results.