Laparoscopic Gastric Banding Outcomes Do Not Depend on Device or Technique. Long-Term Results of a Prospective Randomized Study Comparing the Lapband® and the SAGB®.

BACKGROUND: Gastric banding still represents one of the most widely used bariatric procedures. It provides acceptable weight loss in many patients, but has frequent long-term complications. Because different types of bands may lead to different results, we designed a randomized study to compare the Lapband® with the SAGB®. We hereby report on the long-term results. METHODS: Between December 1998 and June 2002, 180 morbidly obese patients were randomized between Lapband® or SAGB®. Weight loss, long-term morbidity, and need for reoperation were evaluated. RESULTS: Long-term weight loss did not differ between the two bands. Patients who maintained their band had an acceptable long-term weight loss of between 50 and 60 % EBMIL. In both groups, about half the patients developed long-term complications, with about 50 % requiring major redo surgery. There was no difference in the overall rates of long-term complications or failures between the two groups, but patients who had a Lapband® were significantly more prone to develop band slippage/pouch dilatation (13.3 versus 0 %, p < 0,001). CONCLUSIONS: Although in the absence of complication, gastric banding leads to acceptable weight loss; the long-term complication and major reoperation rates are very high independently from the type of band used or on the operative technique. Gastric banding leads to relatively poor overall long-term results and therefore should not be considered the procedure of choice for the treatment of morbid obesity. Patients should be informed of the limited overall weight loss and the very high complication rates.

Evaluation of the inhalation technique in asthmatic children visiting a specialised outpatient clinic

Background and objective: Asthma is one of the most frequent chronic diseases affecting children and adolescents. Good compliance is indispensable for effective treatment since a suboptimal use of inhalation devices can result in decreased therapeutic efficacy and increased morbidity. The objective of this work was to evaluate the inhalation technique of paediatric patients visiting a specialized consultation clinic of a university hospital. Design: Observational prospective study during a 3-month period. Setting Specialized consultation clinic of a university hospital. Main outcome measures: This study involved 40 outpatient infants, children and adolescents visiting alone or with their parent(s). Patients' data (age, sex, weight, diagnostic, reason for consulting, previous consultations) and their medicines were compiled using an ad hoc form. Filmed sequences of the inhalation procedure used by each child were reviewed independently by members of an interdisciplinary team consisting in a physician, a pharmacist, a nurse and a physiotherapist. A score of 1 was assigned to each correct step in the procedure, and a score of 0 to an incorrect step. A perfect procedure implied 12 correct steps. Results: Thirty patients were treated with a metered-dose inhaler and an inhalation chamber (Babyhaler or AeroChamber Plus); ten other patients were treated with a dry powder inhaler (Diskus or Turbuhaler). The agreement between the members of the interdisciplinary team was considered satisfactory. Nine patients (22.5%) reached an average score lower than 7, 18 patients (45%) a score between 7 and 10 and 13 (32.5%) a score equal to or better than 10. No patient reached the maximum score of 12. Users of the metered-dose inhalers (average score = 9.2) showed a better technique than users of the dry powder inhalers (average score = 7.4). Disappointingly, the score was not improved during a second consultation or following regular consultations. Conclusions: Video recording is a simple method to evaluate the degree of mastery of an inhalation procedure in paediatric patients. The method allows a convenient and efficient identification of suboptimal procedure steps by the hospital staff, and opens the way to patient-specific teaching. In two-thirds of juvenile patients, their inhalation technique was suboptimal despite initial training. This study shows conclusively that the inhalation technique in paediatric patients must be monitored during each examination, and teaching measures taken to improve it when necessary.

Technique de reconstruction itérative VEO : évaluation en tomodensitométrie thoracique chez l'enfant.

Objectifs: Evaluer la technique de reconstruction itérative VEO en tomodensitométrie (TDM) du thorax chez l'enfant. Matériels et méthodes: Etude prospective, basée sur 20 patients (7-18 ans), suivis pour mucoviscidose et adressés pour TDM de suivi. Dix patients (groupe A) ont eu une acquisition basse-dose habituelle (BD). Dix patients (groupe B) ont eu une acquisition très-basse-dose (TBD) et ultra-basse-dose (UBD). Les acquisitions BD étaient reconstruites par rétroprojection filtrée (RPF), les acquisitions TBD et UBD étaient reconstruites par RPF et VEO. L'évaluation de VEO était basée sur la réduction de dose et la qualité des images (mesures de bruit et scores de visualisation des structures pulmonaires). Résultats: Une réduction de dose d'environ 50% était obtenue dans le groupe B. La réduction du bruit en VEO par rapport aux RPF était de 55% en TBD et de 75% en UBD. En VEO, une amélioration des scores de visualisation des structures pulmonaires était obtenue en TBD et UBD. Cependant, en VEO-UBD, la visualisation des structures distales demeuraient parfois insuffisante et celle des structures proximales était altérée par une modification de texture de l'image. Conclusion: Malgré une altération possible de la texture de l'image en UBD, la technique de reconstruction VEO est performante en réduction de dose et amélioration des images.

3D coronary vessel wall imaging utilizing a local inversion technique with spiral image acquisition.

Current 2D black blood coronary vessel wall imaging suffers from a relatively limited coverage of the coronary artery tree. Hence, a 3D approach facilitating more extensive coverage would be desirable. The straightforward combination of a 3D-acquisition technique together with a dual inversion prepulse can decrease the effectiveness of the black blood preparation. To minimize artifacts from insufficiently suppressed blood signal of the nearby blood pools, and to reduce residual respiratory motion artifacts from the chest wall, a novel local inversion technique was implemented. The combination of a nonselective inversion prepulse with a 2D selective local inversion prepulse allowed for suppression of unwanted signal outside a user-defined region of interest. Among 10 subjects evaluated using a 3D-spiral readout, the local inversion pulse effectively suppressed signal from ventricular blood, myocardium, and chest wall tissue in all cases. The coronary vessel wall could be visualized within the entire imaging volume.

Stability of the Helical TomoTherapy Hi·Art II detector for treatment beam irradiations.

The Hi·Art II Helical TomoTherapy (HT) unit is equipped with a built-in onboard MVCT detector used for patient imaging and beam monitoring. Our aim was to study the detector stability for treatment beam measurements. We studied the MVCT detector response with the 6 MV photon beam over time, throughout short-term (during an irradiation) and long-term (two times 50 days) periods. Our results show a coefficient of variation ≤ 1% for detector chambers inside the beam (excluding beam gradients) for short- and long-term response of the MVCT detector. Larger variations were observed in beam gradients and an influence of the X-ray target where degradation was found. The results assume that an 'air scan' procedure is performed daily to recalibrate the detector with the imaging beam. On short term, the detector response stability is comparable to other devices. Long-term measure- ments during two 50-day periods show a good reproducibility. 

Improved Surgical Technique Reduces Complications at the Gastro-jejunostomy After Laparoscopic Roux-en-Y Gastric Bypass

Introduction: Roux-en-Y gastric bypass (RYGBP) is one of the commonest procedure for morbid obesity. It is associated with effective long-term weight loss, but can lead to significant complications, especially at the gastrojejunostomy (GJS) Patients and Methods: All the patients undergoing laparoscopic RYGBP at one of our two institutions were included in this study, in which we compared two different techniques for the construction of the GJS and their effects on the incidence of complications. In group A, anatomosis was performed on the posterior aspect of the gastric pouch. In group B it was performed across the staple line used to form the gastric pouch. A 21-mm circular stapler was used in all patients. Results: A total of 1128 patients were included between June 1999 and September 2009, 639 in group A and 488 in group B. Sixty patients developed a total of 65 complications at the GJS, with 14 (1,2 %) leaks, 42 (3,7 %) stricture, and 9 (0,8 %) marginal ulcers. Leaks (0,2 versus 2 %, p=0,005) and strictures (0,8 versus 5,9%, p<0,0001) were significantly fewer in group B than in group A. Conclusions: Improved surgical technique, with the GJS across the staple line used to form the gastric pouch, significantly reduces the rate of anastomotic complications at the GJS. A circular 21-mm stapler can be used with a low complication rate, and especially a low stricture rate. Additional methods to limit complications at the GJS are probably not routinely warranted.

A new technique with high reproducibility to estimate renal oxygenation using BOLD-MRI in chronic kidney disease.

OBJECTIVES: To assess inter-observer variability of renal blood oxygenation level-dependent MRI (BOLD-MRI) using a new method of analysis, called the concentric objects (CO) technique, in comparison with the classical ROI (region of interest)-based technique. METHODS: MR imaging (3T) was performed before and after furosemide in 10 chronic kidney disease (CKD) patients (mean eGFR 43±24ml/min/1.73m(2)) and 10 healthy volunteers (eGFR 101±28ml/min1.73m(2)), and R2* maps were determined on four coronal slices. In the CO-technique, R2* values were based on a semi-automatic procedure that divided each kidney in six equal layers, whereas in the ROI-technique, all circles (ROIs) were placed manually in the cortex and medulla. The mean R2*values as assessed by two independent investigators were compared. RESULTS: With the CO-technique, inter-observer variability was 0.7%-1.9% across all layers in non-CKD, versus 1.6%-3.8% in CKD. With the ROI-technique, median variability for cortical and medullary R2* values was 3.6 and 6.8% in non-CKD, versus 4.7 and 12.5% in CKD; similar results were observed after furosemide. CONCLUSION: The CO-technique offers a new, investigator-independent, highly reproducible alternative to the ROI-based technique to estimate renal tissue oxygenation in CKD.

A critical evaluation of secondary cancer risk models applied to Monte Carlo dose distributions of 2-dimensional, 3-dimensional conformal and hybrid intensity-modulated radiation therapy for breast cancer.

The comparison of radiotherapy techniques regarding secondary cancer risk has yielded contradictory results possibly stemming from the many different approaches used to estimate risk. The purpose of this study was to make a comprehensive evaluation of different available risk models applied to detailed whole-body dose distributions computed by Monte Carlo for various breast radiotherapy techniques including conventional open tangents, 3D conformal wedged tangents and hybrid intensity modulated radiation therapy (IMRT). First, organ-specific linear risk models developed by the International Commission on Radiological Protection (ICRP) and the Biological Effects of Ionizing Radiation (BEIR) VII committee were applied to mean doses for remote organs only and all solid organs. Then, different general non-linear risk models were applied to the whole body dose distribution. Finally, organ-specific non-linear risk models for the lung and breast were used to assess the secondary cancer risk for these two specific organs. A total of 32 different calculated absolute risks resulted in a broad range of values (between 0.1% and 48.5%) underlying the large uncertainties in absolute risk calculation. The ratio of risk between two techniques has often been proposed as a more robust assessment of risk than the absolute risk. We found that the ratio of risk between two techniques could also vary substantially considering the different approaches to risk estimation. Sometimes the ratio of risk between two techniques would range between values smaller and larger than one, which then translates into inconsistent results on the potential higher risk of one technique compared to another. We found however that the hybrid IMRT technique resulted in a systematic reduction of risk compared to the other techniques investigated even though the magnitude of this reduction varied substantially with the different approaches investigated. Based on the epidemiological data available, a reasonable approach to risk estimation would be to use organ-specific non-linear risk models applied to the dose distributions of organs within or near the treatment fields (lungs and contralateral breast in the case of breast radiotherapy) as the majority of radiation-induced secondary cancers are found in the beam-bordering regions.

Transposition of great arteries and single coronary artery: a new surgical technique for the arterial switch operation.

A single coronary artery can complicate the surgical technique of arterial switch operations, impairing early and late outcomes. We propose a new surgical approach, successfully applied in a 2.1 kg neonate, aimed at reducing the risk of early and late compression and/or distortion of the newly constructed coronary artery system.

Free-breathing whole-heart coronary MRA with 3D radial SSFP and self-navigated image reconstruction.

Respiratory motion is a major source of artifacts in cardiac magnetic resonance imaging (MRI). Free-breathing techniques with pencil-beam navigators efficiently suppress respiratory motion and minimize the need for patient cooperation. However, the correlation between the measured navigator position and the actual position of the heart may be adversely affected by hysteretic effects, navigator position, and temporal delays between the navigators and the image acquisition. In addition, irregular breathing patterns during navigator-gated scanning may result in low scan efficiency and prolonged scan time. The purpose of this study was to develop and implement a self-navigated, free-breathing, whole-heart 3D coronary MRI technique that would overcome these shortcomings and improve the ease-of-use of coronary MRI. A signal synchronous with respiration was extracted directly from the echoes acquired for imaging, and the motion information was used for retrospective, rigid-body, through-plane motion correction. The images obtained from the self-navigated reconstruction were compared with the results from conventional, prospective, pencil-beam navigator tracking. Image quality was improved in phantom studies using self-navigation, while equivalent results were obtained with both techniques in preliminary in vivo studies.

Biomechanical stability of a posterior-alone fixation technique after craniovertebral junction realignment.

OBJECTIVE: The aim of the current study was to investigate the biomechanical stability and fixation strength provided by a posterior approach reconstruction technique to realign the craniovertebral junction.¦METHODS: We tested seven human cadaver occipito-cervical spines (occiput-C4) by applying pure moments of ±1.5 Nm on a spine tester. Each specimen was tested in the following modes: 1) intact; 2) injured; 3) spacers alone at C1-C2 articulation (S); 4) spacers plus C1-C2 Posterior Instrumentation (S+PI); and 5) spacers plus C1-C2 posterior instrumentation plus midline wiring (S+PI+MLW). C1-C2 range of motion for each construct was obtained in flexion-extension, lateral bending, and axial rotation.¦RESULTS: In all the loading modes, S, S+PI, and S+PI+MLW constructs significantly reduced range of motion compared with the intact and injured condition (P < 0.05). There was no statistical difference between any of the three instrumentation constructs (P > 0.05).¦CONCLUSIONS: This study investigated the biomechanics of the posterior approach technique for realignment of the craniovertebral junction and also made comparisons with additional posterior fixations. The stand-alone spacers were stable in all three loading modes. Posterior instrumentation increased the stability as compared to stand-alone spacers. The third point of fixation, carried out by using midline wiring, increased the stability further. However, there was not much difference in the stability imparted with the midline wiring versus without. The present study highlights the biomechanics of this novel concept and reaffirms the view that distraction of the C1-C2 articular facets and direct articular joint atlantoaxial fixation would be an ideal method of management of basilar invagination.

Arthro-IRM directe en traction axiale: technique et intérêt [Technique and value of direct MR arthrography applying articular distraction]

Direct MR arthrography has a better diagnostic accuracy than MR imaging alone. However, contrast material is not always homogeneously distributed in the articular space. Lesions of cartilage surfaces or intra-articular soft tissues can thus be misdiagnosed. Concomitant application of axial traction during MR arthrography leads to articular distraction. This enables better distribution of contrast material in the joint and better delineation of intra-articular structures. Therefore, this technique improves detection of cartilage lesions. Moreover, the axial stress applied on articular structures may reveal lesions invisible on MR images without traction. Based on our clinical experience, we believe that this relatively unknown technique is promising and should be further developed.

Spiral CT aortography: an efficient technique for the diagnosis of traumatic aortic injury.

The objective of this study was to assess the efficiency of spiral CT (SCT) aortography for diagnosing acute aortic lesions in blunt thoracic trauma patients. Between October 1992 and June 1997, 487 SCT scans of the chest were performed on blunt thoracic trauma patients. To assess aortic injury, the following SCT criteria were considered: hemomediastinum, peri-aortic hematoma, irregular aspect of the aortic wall, aortic pseudodiverticulum, intimal flap and traumatic dissection. Aortic injury was diagnosed on 14 SCT examinations (2.9 %), five of the patients having had an additional digital aortography that confirmed the aortic trauma. Twelve subjects underwent surgical repair of the thoracic aorta, which in all but one case confirmed the aortic injury. Two patients died before surgery from severe brain lesions. The aortic blunt lesions were confirmed at autopsy. According to the follow-up of the other 473 patients, we are aware of no false-negative SCT examination. Our limited series shows a sensitivity of 100 % and specificity of 99.8 % of SCT aortography in the diagnosis of aortic injury. It is concluded that SCT aortagraphy is an accurate diagnostic method for the assessment of aortic injury in blunt thoracic trauma patients.

Removal of unusual, large high-velocity metallic maxillary sinus foreign bodies by a modified free bone flap technique.

Metallic foreign bodies are rarely found in the maxillary sinus, and usually they have a dental origin.Potential complications related to foreign bodies include recurrent sinusitis, rhinolith formation, cutaneous fistula,chemical poisoning, facial neuralgic pain and even malignancies.Two main surgical approaches are currently used for the removal of foreign bodies in the maxillary sinus: the bone flap and the endoscopic sinus techniques. We are reporting two unusual cases of large high-velocity foreign bodies removed by a modified maxillary lateral antrotomy,with free bone flap repositioning and fixation with a titanium miniplate.