Revision bariatric surgery. What technical choices should be taken depending on the first intervention?

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Preliminary study of efficacy of dynamic compression system in the correction of typical pectus carinatum

Abstract OBJECTIVES: This preliminary study evaluates, by qualitative score, the efficacy of the dynamic compression system (DCS) with a pressuremeasuring device in the treatment of pectus carinatum (PC) as an alternative to surgery. METHODS: A total of 68 patients (infants, adolescents and young adults) presenting with typical PC (64 males and 4 females) were evaluated in our Chest Wall Deformities Unit, between October 2011 and February 2013. The criteria for including subjects were: patients with typical condrogladiolar PC and pressure for initial correction (PIC) ≤ 9 PSI ( pound square inch). Seven patients were excluded in this study: three typical PC were treated by minimal invasive surgery (Abramson technique) due to highly elevated PIC and four atypical PC, hybrids forms (PE and PC) were treated by cup suction for pectus excavatum and by the DCS for the PC. The management protocol included: adjustment of the DCS, strengthening exercises and monthly clinical follow-up. The partial and final results were evaluated by the patients, by their parents or by both, using a qualitative scoring scale that was measured in a three-step grading system, where C is a low or very low result, B is acceptable and A is a very good or excellent result. RESULTS: A total of 61 patients (59 males and 2 females) presenting with typical PC were treated by the DCS and included: symmetric PC in 43 cases and asymmetric PC in 18 cases. The mean age was 13.5 years (5-25). The mean PIC was 6.3 PSI (3-9 PSI). The mean utilization time was 19 h daily. The patients were divided into three groups. In Group I, consisting of 35 cases, all the patients have already completed the treatment with excellent aesthetic results (A). In 12 cases, Group II, the normal shape of the thorax has been obtained; all the patients in this group rated their results as excellent (A); however, these patients are still wearing the brace as a retainer for 3 additional months. Fourteen patients, Group III, are progressing and improving under active treatment, and surgeons and patients are very satisfied with the initial results. None of the 61 patients in this study abandoned the treatment and no complications were found. CONCLUSIONS: This preliminary study demonstrated that the DCS with a pressure-measuring device is a minimal invasive system effective for treatment of PC in patients where the anterior chest wall is still compliant. The control of different pressure measurements could be used as the inclusion criterion as well as a predictive factor for aesthetic results and treatment duration

Could lymphatic mapping and sentinel node biopsy provide oncological providence for local resectional techniques for colon cancer? A review of the literature

<p>Abstract</p> <p>Background</p> <p>Endoscopic resectional techniques for colon cancer are undermined by their inability to determine lymph node status. This limits their application to only those lesions at the most minimal risk of lymphatic dissemination whereas their technical capacity could allow intraluminal or even transluminal address of larger lesions. Sentinel node biopsy may theoretically address this breach although the variability of its reported results for this disease is worrisome.</p> <p>Methods</p> <p>Medline, EMBASE and Cochrane databases were interrogated back to 1999 to identify all publications concerning lymphatic mapping for colon cancer with reference cross-checking for completeness. All reports were examined from the perspective of in vivo technique accuracy selectively in early stage disease (i.e. lesions potentially within the technical capacity of endoscopic resection).</p> <p>Results</p> <p>Fifty-two studies detailing the experiences of 3390 patients were identified. Considerable variation in patient characteristics as well as in surgical and histological quality assurances were however evident among the studies identified. In addition, considerable contamination of the studies by inclusion of rectal cancer without subgroup separation was frequent. Indeed such is the heterogeneity of the publications to date, formal meta-analysis to pool patient cohorts in order to definitively ascertain technique accuracy in those with T1 and/or T2 cancer is not possible. Although lymphatic mapping in early stage neoplasia alone has rarely been specifically studied, those studies that included examination of false negative rates identified high T3/4 patient proportions and larger tumor size as being important confounders. Under selected circumstances however the technique seems to perform sufficiently reliably to allow it prompt consideration of its use to tailor operative extent.</p> <p>Conclusion</p> <p>The specific question of whether sentinel node biopsy can augment the oncological propriety for endoscopic resective techniques (including Natural Orifice Transluminal Endoscopic Surgery [NOTES]) cannot be definitively answered at present. Study heterogeneity may account for the variability evident in the results from different centers. Enhanced capacity (perhaps to the level necessary to consider selective avoidance of en bloc mesenteric resection) by its confinement to only early stage disease is plausible although not proven. Specific study of the technique in early stage tumors is clearly essential before proffering this approach.</p

A comprehensive overview of radioguided surgery using gamma detection probe technology

The concept of radioguided surgery, which was first developed some 60 years ago, involves the use of a radiation detection probe system for the intraoperative detection of radionuclides. The use of gamma detection probe technology in radioguided surgery has tremendously expanded and has evolved into what is now considered an established discipline within the practice of surgery, revolutionizing the surgical management of many malignancies, including breast cancer, melanoma, and colorectal cancer, as well as the surgical management of parathyroid disease. The impact of radioguided surgery on the surgical management of cancer patients includes providing vital and real-time information to the surgeon regarding the location and extent of disease, as well as regarding the assessment of surgical resection margins. Additionally, it has allowed the surgeon to minimize the surgical invasiveness of many diagnostic and therapeutic procedures, while still maintaining maximum benefit to the cancer patient. In the current review, we have attempted to comprehensively evaluate the history, technical aspects, and clinical applications of radioguided surgery using gamma detection probe technology

MORPHEUS : évaluation de l’efficacité de la morphine sur la réduction du taux d’échecs précoces de ventilation non invasive lors des exacerbations de bronchopneumopathies chroniques obstructives essai clinique de phase I/IIa par méthode de réévaluation continue

Phase I/IIa clinical trial assessing the toxicity and effectiveness of morphine in reducing the early failures of non-invasive ventilation in exacerbated COPD patients (population in intention to treat). The goal is to find a safe dose that will be used for later phases of the trial. The clinical trial took place in the pneumology, the intensive care and the emergency department of the University hospital of Grenoble. Patients were included sequentially, and each were assigned a dose of morphine. Patients were then followed for 4 hours in order to record the toxic effects and the effectiveness of the treatment. The choice of the dose was made by a continual reassessment method whose goal is to choose the doses to be given to patients according to their probability of toxicity and efficacy. Here we have chosen an approach using an adaptive Bayesian dose-finding procedure with two models: a logistic model for a binary response (DLT) and a random walk model for a continuous response (the biomarker representative of effectiveness, here PaCO2). A gain function is used to objectively represent the trade-off between effectiveness and security. Inclusion were delayed due to the pandemic, preventing us to show results in this document. We will only present here a feedback on application of the method. This approach seems promising to limit the risk of toxicity during a phase I clinical trial. It also makes it possible to group phases I and IIa, limiting the number of patients to be included. However, it remains complex to set up and requires particular attention to the definition of priors for the models.La broncho-pneumopathie chronique obstructive est une affection pulmonaire fréquente avec de multiple conséquences systémiques. La morbi-mortalité est principalement dû aux épisodes d’exacerbation aiguë, avec une mortalité hospitalière d’environ 8 %. Le traitement de ces exacerbations repose sur la ventilation non invasive. Cependant, les échecs de ce traitement sont fréquent, et sont associés à une mortalité hospitalière élevée. Une piste pour réduire les échecs précoces de VNI est l’amélioration du confort et de la dyspnée du patient. L’utilisation de morphine pourrait réduire les symptômes d’hypoxie, d’hypercapnie et la sensation de suffocation. Avant de réaliser un essai clinique pour tester l’efficacité de cette approche, il était nécessaire de réaliser les études de phases I et II. Du fait de la toxicité particulière des opiacés chez les patients présentant une exacerbation aiguë de BPCO, la phase I ne pouvait être sur des patients sains. Afin de limiter le risque d’événement toxique, et de réduire le nombre de patients exposé lors de ces phases précoces, nous avons mis en place une méthodologie innovante permettant de regrouper les phases I et IIa. Cette approche modélise la toxicité et permet ainsi d’obtenir une estimation de celle-ci en cours d’étude, limitant le risque de surdosage. Le contexte particulier de cette année a malheureusement retardé la période d’inclusion, nous empêchant de présenter ici des résultats. Nous nous contenterons donc de présenter un retour d’expérience. Cette approche paraît prometteuse afin de limiter le risque de toxicité lors d’essai clinique de phase I. Elle permet aussi de regrouper les phases I et IIa, limitant le nombre de patients à inclure. Elle reste cependant complexe à mettre en place et requière une attention particulière à l’initialisation des modèles. Elle pourrait aussi être utile dans le cas de polymédication, afin d’identifier plus facilement le traitement à l’origine des effets indésirables