Daniel Navarini

The Impact of Gastric Bypass on Gastroesophageal Reflux Disease in Patients With Morbid Obesity: A Prospective Study Based on the Montreal Consensus

Objectives:To assess the impact of gastric bypass (GBP) on gastroesophageal reflux disease (GERD) based on Montreal Consensus. Methods:In this study, 86 patients (25 men; aging 38 ± 12 years; body mass index 45 [35–68 kg/m2]) were investigated for GERD before GBP and 6 months later. Esophageal and extraesophageal syndromes were assessed based on Montreal Consensus. Esophageal acid exposure and gastric pouch acidity were also evaluated. Results:Overall prevalence of GERD was 64% before GBP and 33% after GBP (P < 0.0001). Typical reflux syndrome (TRS) was present in 47 patients (55%) preoperatively and disappeared in 39 of them (79%) post-GBP. Out of 39 patients with no symptoms, 4 (10%) developed TRS postoperatively (P < 0.0001). The chief TRS complaint changed from heartburn pre-GBP (96%) to regurgitation post-GBP (64%). Esophageal mucosa improved in 27, was unchanged in 51, and worsened in 8 patients (P = 0.001) in regard of esophagitis. Extraesophageal syndromes were present in 16 patients preoperatively and in none but one post-GBP (P = 0.0003). GERD-related well being and use of proton pump inhibitors were both improved after GBP. Total acid exposure decreased from a median (interquartile range, 25%–75%) of 5.1% (range, 2–8.2) to 1.1% (range, 0.2–4.8), P = 0.0002. Most patients (86%) showed and acid gastric pouch in fasting conditions post-GBP. Conclusions:GBP ameliorated GERD syndromes in most patients 6 months after the procedure, resulting in quality of life improvement and less proton pump inhibitors usage. Whether regurgitation post-GBP corresponds to reflux disease or bad eating behavior deserves further studies.

Epidermal Growth Factor Receptor Expression in Esophageal Adenocarcinoma: Relationship with Tumor Stage and Survival after Esophagectomy

Background and Aims. Esophageal adenocarcinoma (EA) is an aggressive tumor with increasing incidence in occidental countries. Several prognostic biomarkers have been proposed, including epidermal growth factor receptor (EGFR). The aim of this study was to assess whether EGFR expression predicts EA staging and patient survival. Methods. In this historical cohort, consecutive patients with EA managed between 2000 and 2010 were considered eligible for the study. Surgical specimens of patients treated with transhiatal esophagectomy were evaluated to establish EGFR expression and tumor differentiation. Staging was classified according with tumor-node-metastasis (TNM) system. Survival was determined according to either medical register or patients family contact. Results. Thirty-seven patients who underwent esophagectomy without presurgical chemotherapy or radiotherapy were studied. EGFR expression was found in 16 patients (43%). EGFR expression was more frequent as higher was the TNM (I and II = 0% versus III = 47% versus IV = 100%; P < 0.001). Average survival in months was significantly shorter in the group of patients with EGFR expression (10.5 versus 21.7; P = 0.001). Conclusions. In patients with esophageal adenocarcinoma treated with transhiatal esophagectomy, EGFR expression was related to higher TNM staging and shorter survival. EGFR expression might be assumed as a prognostic marker for esophageal adenocarcinoma.

Incarcerated right-sided diaphragmatic hernia in a patient undergoing Roux-en-Y gastric bypass

Bochdalek hernia is the most common congenital diaphragmatic hernia. Its symptoms are normally diagnosed and treated during the neonatal period. Conversely, in adults it is usually asymptomatic and, as a consequence, this group is misdiagnosed. A case of a 64-year-old female patient with an uncommon incarcerated right-sided diaphragmatic hernia formed three years after a Roux-en-Y gastric bypass and a significant weight loss is reported. The importance of this abnormality as a complication of the bariatric surgery should be considered. Key words: Diaphragmatic hernia; gastric bypass; bariatric surgery.

Mirizzi Syndrome Type IV: A challenging diagnosis

Mirizzi Syndrome type IV is an extremely rare condition, which is confused with the diagnosis of cholangiocarcinoma in many cases. This report describes a case of a forty-three-year old patient, who was forwarded to our department of general surgery with a high suspicion of a choledochal neoplasic lesion. During the hospitalization he was diagnosed with Mirizzi Syndrome type IV. We concisely describe the case and the literature review about this pathology.

Mo1879 EGFR in Gastroesophageal Reflux Disease, Barrett's, Esophagus, and Esophageal Adenocarcinoma

Adipose tissue has been shown to produce a number of inflammatory cytokines and may play a role in the development and progression of several inflammatory diseases. Accumulation of intra-abdominal fat correlates more strongly with inflammatory disease states than does total body fat, suggesting depot-specific differences in the inflammatory potential of adipose tissue. In inflammatory bowel disease specifically, recent clinical studies suggest that patients with increased intra-abdominal fat may suffer a more aggressive clinical course. Objective: The purpose of the present study was to evaluate the significance of inflammatory cytokine production by various adipose tissue depots during acute experimental colitis. Methods: Colitis was induced in C57BL mice by addition of 2% dextran sulfate sodium (DSS) to drinking water for 5 days. Mice were sacrificed at Day 3, 7, 14, and 21 following initiation of DSS treatment. Control mice were sacrificed prior to initiation of treatment. Plasma cytokine levels at time of sacrifice were analyzed by multiplex assays. Colonic tissue damage was evaluated histologically by H&E staining. Tissue levels of cytokine mRNAwere compared between the colon, 3 adipose tissue depots (mesenteric, epididymal, and subcutaneous), kidney, and liver by qRT-PCR. Results: Histologic evidence of colitis and significantly increased plasma IL-6 levels were evident by Day 7 and peaked at Day 14. Changes in cytokine expression within the colon occurred earlier, with significant increases in TNF-a, IL-1b, and IL-6 mRNA all evident by Day 3 (P=0.016). Of the cytokines analyzed, IL-6 in the colon exhibited the most profound increase with colitis, with levels at Day 7 increased 230-fold from baseline (P=0.002). Analysis of adipose tissues from this time point revealed that while IL-6 mRNA expression in mesenteric and epididymal adipose tissue was significantly increased compared to controls, 8.6-fold (P=0.016) and 3.8-fold (P=0.004) respectively, no increase in subcutaneous adipose tissue IL-6 mRNA was observed. Multi-tissue analysis at this time point revealed that mesenteric and epididymal adipose tissue expressed significantly more IL-6 mRNA than the kidney or the liver, whose levels of IL-6 did not increase significantly from baseline. Conclusions: This study demonstrates that intra-abdominal adipose tissue is a major source of IL-6 during acute experimental colitis. The time course analysis suggests that intra-abdominal fat may have a significant impact on plasma IL-6 levels. Unlike the mesentery, the epididymal fat pad is not contiguous with the inflamed bowel and does not contain the venous or lymphatic drainage of the affected bowel. This suggests a tissue-specific response by the intra-abdominal adipose tissue, rather than merely a local lymphoid reaction to tissue damage in the colon.