Ariola Hasani

Acinic cell carcinoma of the breast: Review of the literature

INTRODUCTION The breast and salivary gland tissue share embryologic and thus pathological similarities. Acinic cell carcinoma (ACC) is a typical tumor in salivary glands, but rarely arises in breast too. We reviewed 38 cases of mammary ACC reported in literature and our case, the first ACC born within a fibroadenoma. MATERIALS AND METHODS Data were collected by a research for the key words acinic cell carcinoma breast on Pubmed in March 2014, including a case treated in our department. All reviewed cases were compared for clinical approach and histological pattern. RESULTS To date 23 articles presenting cases of ACC of the breast are reported in literature. We included in our review 38 cases previously described and one new case. The histological pattern was predominantly solid with a microglandular structure. All the tumor cells were cytologically characterized by monotonous round cells with a finely granular, weakly eosinophilic, or clearly vacuolated cytoplasm. The most of the cells were intensely stained with anti-lysozime, anti-amylase, anti-α1-chimotripsin, anti-EMA and anti-S100 protein antisera. Immunohistochemistry was also performed to point out: estrogen receptor (ER), progesterone receptor (PR), androgen receptors (AR), human epidermal growth factor receptor 2 overexpression (HER2/neu), E-cadherin (E-cad), cytokeratin-7 (CK7), gross cystic disease fluid protein 15 (GCDFP15), smooth muscle actin (SMA). CONCLUSION ACC of the breast is a rare tumor, showing similarities with the salivary gland counterpart, above all in terms of good prognosis, and differences from the ordinary invasive breast carcinoma. Further investigations are needed to elucidate the true histogenesis and the correct treatment.

Five-year results of laparoscopic sleeve gastrectomy: effects on gastroesophageal reflux disease symptoms and co-morbidities

BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is becoming the most performed bariatric procedure; however, data available on long-term follow-up are scanty. OBJECTIVES The aim of the present study was to evaluate the 5-year efficacy of LSG on weight loss, gastroesophageal reflux disease (GERD) symptoms, and obesity-associated co-morbidities. SETTING Tertiary-care referral hospital. METHODS This study retrospectively analyzed 105 obese patients undergoing LSG from January 2006 to December 2009. The preoperative evaluation included demographic characteristics, evaluation of co-morbidities, a double-contrast barium swallow, and an upper-gastrointestinal endoscopy. The following data were collected at 1, 3, and 5 years after surgery: weight, improvement/remission of co-morbidities, complications, and revisional surgery. RESULTS According to preoperative body mass index (BMI), patients were divided into Group 1 (n = 61) with BMI≤50 kg/m(2) and Group 2 (n = 44) with BMI>50 kg/m(2). The follow-up rate was 94% after 5 years (n = 99). Delta BMI (BMI at follow-up-preoperative BMI) was significantly higher in Group 2 than in Group 1 at 1-3 years and 5 years (P<.001). Furthermore, at 5 years, Group 2 showed a significantly higher percentage total weight loss (%TWL) (26.6%±18.3% versus 33.5%±12.9%, P = .006) than Group 1, whereas percentage excess weight loss was similar (58.4%±21.8% versus 55.3%±19.5%, P = .5).Younger age at surgery and absence of postoperative GERD were associated with a better %TWL at 5 years (P<.001 and P = .03). CONCLUSION LSG is an effective procedure at long-term, with good weight loss outcomes and with a considerable improvement of obesity-associated co-morbidities. Younger age at surgery and absence of postoperative GERD were associated with a better %TWL at 5 years.

Revisional Surgery after LAGB

Laparoscopic adjustable gastric banding (LAGB) is generally safe and well tolerated but complications are not infrequent. As with all other bariatric procedures, there are patients who experience poor weight loss or even weight regain at long term follow up. Some of these complications require prompt management whereas more chronic problems require careful work up involving the multidisciplinary team. All complications require a resolution and revision tailored to the individual. Revision of failed or complicated LAGB should be performed by an experienced bariatric team. A wide range of endoscopic and laparoscopic procedures can be offered to patients with LAGB complications. Management of these issues often requires explanting the device, with or without proceeding to more definitive measures. Invariably, there will be a subgroup of patients with interval weight regain, especially if the gastric band is removed without any immediate salvage or replacement procedure. Redo surgery for LAGB is still a gray area of bariatric surgery. Large experiences with long follow up are lacking and high grade level evidence based experiences are also absent. Overall, outcomes in terms of weight loss and complications are controversial according to different experiences.

Endoscopic Septotomy for the Treatment of Sleeve Gastrectomy Fistula: Timing and Indications

To the Editor, We read with great interest the Letter to the Editor entitled BEndoscopic Abscess Septotomy for Management of Sleeve Gastrectomy Leaks^ [1]. Gastric leak (GL) after bariatric surgery is one of most dreaded complications due to its associated high morbidity and mortality, and the treatment of leaks following sleeve gastrectomy (SG) represents indeed one of the most debated topic, also due to the steep increase of this procedure among the performed bariatric procedures [2]. No standard protocol for management of GL exists, and surgical revision is often unsuccessful and burdened with high post-operative complications [3]. Deployment of self-expanding metallic stents (SEMS) still is the most popular endoscopic approach to GL with several studies being published; however, the success rate is very variable and its role has been re-evaluated [4–6]. Donatelli suggests that rather than bypassing the leak with SEMS, the key to success is to accomplish complete internal drainage of any collection [3, 7]. They suggest an algorithm for the use of endoscopic internal drainage (EID) with or without enteral nutrition as first-line management of GL following SG, with good outcomes. Double-pigtail stents keep the leak orifice open favoring the passage of fluid content into the digestive lumen with progressive reduction in the collection size until it eventually becomes a virtual cavity. Meanwhile, a foreign body reaction in the edges of the leak is triggered by plastic stents promoting the re-epithelialization over the stent and the fistula closure, resulting in an all-in-one procedure without the need of further treatment [3, 7, 8]. The same principle is maintained by the technique proposed in this letter [1]. Septotomy entails endoscopic dissection of the septum that separates the sleeve lumen and the perigastric cavity, to equalize the pressure between the two cavities to allow drainage of the perigastric collection into the gastric lumen [9, 10]. However, we believe that a standardization of this technique is necessary, its indications should be accurately explained, and the timing of its application should be defined. Is this technique to be approached only when other options (SEMS, clips, glue, pig tails, etc.) fail? Or is it a second step of the EID with double pigtails? These are only some of the questions to which surgeons performing SG want to give an answer: what to do and when to do it, when we face a post-SG leak or fistula. The definitions are as important as the concept itself: leak or fistula. As better reported by Souto-Rodriguez, leaks are defined as the exit of luminal contents due to a discontinuity of the tissue apposition at the surgical anastomosis, whereas fistulas are abnormal passage ways usually between two hollow viscera or communicating to the skin and they result from chronic healing of local inflammation caused by leaks [11]. The clinical classification of leaks/fistula of Rosenthal is Obesity Surgery (2018) 28:846–847 https://doi.org/10.1007/s11695-017-3071-1

Gastric Bypass and Synchronous Cholecystectomy: Not Only Numbers

To the Editor, We read with great interest the letter entitled BGastric bypass and synchronous cholecystectomy: a matter of numbers?^. The authors claim that synchronous cholecystectomy in patients undergoing bariatric surgery should be reserved only to symptomatic patients, because risks of prophylactic cholecystectomy in asymptomatic cholelithiasis are higher than potential benefits. According to recent recommendations on the management of gallstone disease from the National Institute for Health and Care Excellence (NICE) [1], people with asymptomatic gallbladder stones found in a normal gallbladder and normal biliary tree do not need treatment unless they develop symptoms. However, the potential benefit of prophylactic cholecystectomy performed concomitantly with non-biliary abdominal surgery (i.e., bariatric surgery) remains a topic of debate [2, 3] and other factors should be taken into account. Previous studies demonstrated that the fast and massive weight loss after all type of bariatric procedures increased the risk of cholesterol stones in supersaturated bile [4, 5], but this risk is higher after RYGB for different reasons: impaired gallbladder emptying (caused by fat malabsorption); decreased cholecystokinin secretion (due to duodenal exclusion), reduced ghrelin production, and damage of the vagal trunks or branches during dissection of the lesser curvature [6]. Percentage of symptomatic lithiasis after bariatric surgery can reach 30–40% [7, 8]; this means that more than 1 out 5 patients will undergo cholecystectomy in the years following RYGB, with some technical challenges to the surgeon. In fact, adhesions that occur following foregut surgery could make laparoscopic visualization of gallbladder more difficult [9, 10]. It should be considered the higher risk of a second laparoscopic access in those patients and the possibility of iatrogenic biliary lesions especially in cholecystectomies for acute cholecystitis or in elderly patients. The relatively low incidence of symptomatic lithiasis reported by the meta-analysis cited in the letter [11] is itself a weak argument: the main limitation is the short follow-up time of most of included trials. About half of them in fact had a follow-up of <18 months, but the time to development of new gallstones after RYGB is unknown [7, 12]. Since 1999, 535 laparoscopic RYGBs were performed in our center; in 37 (6.9%) patients, a concomitant cholecystectomy was performed for asymptomatic cholelithiasis. At follow-up, 78 (15%) subjects developed a cholelithiasis and underwent a second intervention to remove the gallbladder. Neither mortality nor major morbidity were reported among concomitant cholecystectomies and second step cholecystectomies. However, the second laparoscopic access led to higher operative risk, due to adherences, with longer operative time. * Luigi Angrisani luigiangrisani@chirurgiaobesita.it

Revisional or Conversion Procedures for Roux-en-Y Gastric Bypass Failure

Surgery for morbid obesity has been carried out since 1950s, but it was only after the introduction of biliopancreatic diversion by Scopinaro that the surgical approach to obesity gain worldwide consensus and diffusion [1, 2]. During the years, gastric restrictive procedures, malabsorptive or combined procedures were introduced in the bariatric surgical praxis [3, 4]. Several experiences reported risk and benefit of each procedure, and the even increasing number of operated patients run parallel with a similar increase of re-do operations [5, 6]. Re-do bariatric surgical procedures are mainly indicated for two reasons. The first reason is the presence of an acute or chronic complication or a side effect of the primary bariatric procedure or metabolic and nutritional sequel. The second is the absence of postoperative weight loss or the weight regain after a successful period, untreatable with conservative approach [7–11]. Re-do bariatric procedures can be divided into conversions and revisions. Conversion surgery is defined as the exchange of a bariatric procedure to another one. Revision surgery is defined as the modification of the primary bariatric procedure without changes of its anatomical scheme.