Federica Murelli

A 15-year evaluation of biliopancreatic diversion according to the Bariatric Analysis Reporting Outcome System (BAROS).

Background: Biliopancreatic diversion (BPD) is the most effective bariatric procedure in terms of weight loss. However, analysis of the quality of life (QoL) has never been reported. The BAROS, giving a score to each operated patient on weight loss, improvement in medical conditions, QoL, complications and reoperations, has proven to be a standard reference for evaluating bariatric surgery outcomes. Methods: In order to apply the BAROS to BPD, we sent a questionnaire to 1,800 BPD patients who had been operated between 1984 and 1998.The responserate was 51.2%. Out of 1,709 questionnaires which actually reached their destination, we had 858 fully compiled returned. There were 615 women. 596 patients had had an ad hoc stomach (AHS) BPD, and 262 had had an ad hoc stomach ad hoc alimentarylimb (AHS-AHAL) BPD. Results: According to the scoring key, 3.5% were classified as a failure, 11% were fair results, 22.8% good, 39.5% very good , and 23.2% excellent results. Considering AHS BPD and AHS-AHAL BPD separately,while the mean excess weight percent loss was 70.5±23 and 64.7±17 respectively, the failure rate was 6% in the first group and 2% in the AHAL group, while 11% and 6% of cases respectively were fair results, 24% and 20% good, 36% and 47% very good, 23% and 25% excellent results. Conclusion: The BAROS evaluation of BPD highlights the importance of its flexibility: the new policy of adapting the procedure to individual characteristics caused a drop in the failure rate and an increase in good, very good and excellent results.

Energy and Nitrogen Absorption after Biliopancreatic Diversion

Background: The strict long-term weight maintenance in good nutritional conditions observed after biliopancreatic diversion (BPD) needs to be explained. Materials and Methods: 15 operated subjects were maintained at an isoenergetic and isonitrogenic diet as similar as possible to their usual diet. Apparent absorption (AA) of energy, fat, nitrogen and calcium was calculated subtracting the fecal content, measured directly, from the oral intake, derived from tables.The alimentary protein absorption was directly determined by I125 albumin oral administration. Results: Mean AA for energy and fat was 57% and 32%, respectively; AAs were unrelated as absolute value and negatively associated as percent of the intake with the energy and fat intake. I125 intestinal absorption was 73%, while nitrogen percent AA was 57%, indicating higher than normal loss of endogenous nitrogen. Calcium AA was 551 mEq/day, 26% of the intake. A positive correlation between nitrogen and calcium AA as absolute values and alimentary intake was observed, while there was no correlation when AA were considered as per cent of the intake. Conclusions: For energy and fat, an increase in intake corresponds to an increase in percent malabsorption, so that the absolute amount absorbed tends to remain constant, accounting for the excellent weight maintenance observed following BPD. This was confirmed by a long-term hypernutrition study after BPD. On the contrary, for nitrogen and calcium, the percent absorption tends to remain constant when intake varies, so that an increase in alimentary intake results in an increased absolute amount absorbed.

Liver damage in severely obese patients: a clinical-biochemical-morphologic study on 1,000 liver biopsies.

Background: Preoperative clinical and biochemical data and intraoperative liver biopsy of 1,000 obese patients submitted to biliopancreatic diversion (BPD) were analyzed, and correlations investigated. Methods: Of 2,645 patients submitted to BPD between May 1976 and November 2002, the last 1,000 consecutive obese patients with no history of alcohol consumption or infectious hepatitis were selected. Clinical data included: age, body weight, BMI, waist-to-hip ratio (W/H), arterial blood pressure, serum glucose, triglycerides, cholesterol, albumin/γ-globulin ratio, total, conjugated and unconjugated bilirubin, γ-GT, alkaline phosphatase, AST, ALT, and prothrombin time. The degree of steatosis, inflammation and fibrosis on intraoperative wedge liver biopsy was determined and scored. Liver steatosis >70% and presence of bridging fibrosis were analyzed separately. Results: Mean BMI was 48 kg/m2. 263 patients had steatosis of >70%, and 79 had bridging fibrosis. Regression analysis showed an association between steatosis and AST, ALT, AST/ALT ratio, body weight, W/H, serum glucose, serum tryglicerides, BMI, γ-GT, age, and unconjugated bilirubin. Inflammation was significantly greater in older patients. Patients with bridging fibrosis had significantly higher values of serum glucose, AST, γ-GT, serum cholesterol and were significantly older. Bridging fibrosis was associated with diabetes, W/H >1, hypertension, albumin/γ-globulin ratio <1. Conclusion: Severe steatosis and bridging fibrosis seem to be associated with the metabolic syndrome. No reliable biochemical data could identify patients with severe chronic liver damage with sufficient sensitivity to avoid liver biopsy for diagnosis and staging of the disease.

Lymphedema Microsurgical Preventive Healing Approach: A New Technique for Primary Prevention of Arm Lymphedema After Mastectomy

BackgroundThe purpose of this manuscript is to assess the efficacy of direct lymphaticvenous microsurgery in the prevention of lymphedema following axillary dissection for breast cancer.MethodsNineteen patients with operable breast cancer requiring an axillary dissection underwent surgery, carrying out LVA between the blue lymphatics and an axillary vein branch simultaneously. The follow-up after 6 and 12 months from the operation included circumferential measurements in all cases and lymphangioscintigraphy only in 18 patients out of 19 cases.ResultsBlue nodes in relation to lymphatic arm drainage were identified in 18/19 patients. All blue nodes were resected and 2-4 main afferent lymphatics from the arm could be prepared and used for anastomoses. Lymphatic-venous anastomoses allowed to prevent lymphedema in all cases. Lymphangioscintigraphy demonstrated the patency of microvascular anastomoses.ConclusionsDisruption of the blue nodes and closure of arm lymphatics can explain the significantly high risk of lymphedema after axillary dissection. LVA proved to be a safe procedure for patients in order to prevent arm lymphedema.

Outcome of Biliopancreatic Diversion in Subjects with Prader-Willi Syndrome

Background: In Prader-Willi Syndrome (PWS), mental retardation and compulsive hyperphagia cause early obesity, the co-morbidities of which lead to short life-expectancy, with death usually occurring in their 20s. Long-term weight loss is mandatory to lengthen the survival; therefore, the lack of compliance in voluntary food restriction requires a surgical malabsorptive approach. Methods: 15 PWS subjects were submitted to biliopancreatic diversion (BPD) and followed (100%) for a mean period of 8.5 (4-13) years. BPD consists of a distal gastrectomy with a long Roux-en-Y reconstruction which, by delaying the meeting between food and biliopancreatic juices, causes an intestinal malabsorption. Indication for BPD was BMI >40 or >35 with metabolic complications. Preoperative mean age was 21±5 years, mean weight 127±26 kg, and mean Body Mass Index (BMI, kg/m2) 53±10. According to Holms criteria, all of the subjects had a total score ≥8. IQ assessment was performed in each subject, with a mean score of 72±10. An arbitrary lifestyle score was given to each subject. Results: No perioperative complications were observed. Percent excess weight loss (%EWL) was 59±15 at 2 years and 56±16 at 3 years, and then progressive regain occurred; at 5 years %EWL was 46±22 and at 10 years 40±27. Spearman rank test failed to demonstrate any correlation between weight loss at 5 years and patient data, except with lifestyle score (Spearman r=0.8548, p<.0001). Current mean age is 31±7 years. Conclusion: BPD has to be considered for its value in prolonging and qualitatively improving the PWS patients life.

Short-Term Liver Function after Biliopancreatic Diversion

Background: Liver failure after biliopancreatic diversion (BPD) has been reported. Although in our series of 2,515 BPD with a minimum follow-up of 12 months we have never observed this complication, a transitory and significant rise in serum AST and ALT has been detected in some cases, suggesting the occurrence of transient liver damage. To assess if risk factors for acute liver damage after BPD could be identified, we studied the evolution of hepatic biochemistry in a sample of our operated subjects. Methods: We studied 99 consecutive patients submitted to the same type of BPD (ad hoc stomach, ad hoc alimentary limb). Patients with a history of alcohol consumption or positive hepatic serology were excluded. Preoperative body weight (BW), body mass index (BMI), excess weight (EW), % excess weight (%EW), fasting serum glucose level (SG), hepatic histology (HI), weight loss (WL) at 2, 4 and 12 months, and excess weight % loss (IEW%L) at the same time were correlated with preoperative and 2, 4 and 12 months hepatic biochemistry. Results: Compared with preoperative values, AST levels at 2 months significantly increased (Students t-test, P=0.0003) and significantly decreased at 12 months (P=0.0001). Spearmans Rank test showed significant correlations between 2 months AST levels and WL at 2 months (P =0.005), preoperative BW (P <0.0001), SG (P =0.01), and HI (inflammation P<0.0001, fibrosis P=0.001). Conclusion: Hepatocellular necrosis in our series peaks at 2 months, and decreases afterwards.WL at 2 months, preoperative BW, SG and HI seem to be of help in identifying patients at increased risk for acute liver damage, prompting the need for an enhanced surveillance.

Effect of biliopancreatic diversion on hypertension in severely obese patients

Hypertension is a medical disorder frequently associated with severe obesity, and the effect of weight loss on the reduction of blood pressure has been well established. In this study, the relationships between the weight loss surgically obtained by biliopancreatic diversion and blood pressure were investigated in a population of severely obese patients with preoperative hypertension. At 1 year following the operation, blood pressure was normalized in more than half of patients; in a further 10% of cases the hypertensive status resolved within the 3-year follow-up period. The resolution of hypertension was independently associated with age and body weight and was unrelated to sex, the amount of weight loss, or body fat distribution. In severely obese patients with hypertension undergoing bariatric surgery, biliopancreatic diversion is advisable since it achieves and supports the maintenance of body weight close to the ideal value.

Squamous cell carcinoma of the breast: a case report

IntroductionPure primary squamous cell carcinoma of the breast is uncommon and its debated the correct management of this disease.Case presentationA 54-years-old woman presented with signs and symptoms of mastitis of left breast. A palpable well circumscribed and firm mass, measuring about 40 mm, was present in the left lower lateral quadrant. She underwent antibiotic therapy without benefit. She performed an ultrasound and mammographic scan of the left breast. Fine needle aspiration cytology revealed an infiltrative poorly differentiated squamous cell carcinoma. Total body CT scan and bone scan excluded distant metastasis. Subsequently wide local excision of the left breast with ipsilateral axillary lymph nodes dissection was performed. The pathological examination revealed an infiltrative poorly differentiated squamous cell carcinoma of the breast. Adjuvant chemotherapy cisplatin and 5-fluorouracil based was administered. Patient refused locoregional radiotherapy. Twenty-eight months after surgery the patient was disease free.ConclusionsPure primary squamous cell carcinoma of the breast is a rare and aggressive disease often treatment-refractory. An optimal systemic treatment is needed to improve patients outcome.

Orbital swelling as a first symptom in breast carcinoma diagnosis: a case report

IntroductionThe frequency of intra-orbital metastasis in systemic cancer is a controversial topic. Of all metastatic tumors to the orbit of the eye, breast carcinoma is considered to be the most prevalent. Orbital findings typically present themselves after the diagnosis of the primary tumor, with an average delay of three to six years. In spite of that, this study reports a case in which orbital manifestation was the initial symptom in breast carcinoma diagnosis.Case presentationA 66-year-old Italian Caucasian woman presented with a swelling located on the lower orbit of her right eye.ConclusionsPrevious cases report orbital manifestations discovered secondary to breast cancer. This case demonstrates that orbital symptoms may be the primary presentation of the disease. Orbital metastasis originating from breast cancer predicts widespread metastatic disease in other organs. In the presence of an ambiguous infiltrative orbital process, diagnostic examination of the breast is recommended.

Pregnancy in Formerly Type 2 Diabetes Obese Women Following Biliopancreatic Diversion for Obesity

BackgroundThis study describes the pregnancy of previously obese women with type 2 diabetic who reduced body weight and normalized serum glucose level following biliopancreatic diversion (BPD) for obesity.MethodsA subset of ten women who had type 2 diabetes prior to BPD and who developed pregnancy after the operation was retrospectively identified.ResultsAll pregnancies were completely normal, and serum glucose levels remained within the physiological range throughout all the pregnancy. These post-diabetic women delivered 13 infants in good health with a normal birth weight and no case of macrosomia.ConclusionsThese data are a clinical confirmation of the post-BPD improvement of beta-cell response to increased functional demand in obese patients with preoperative type 2 diabetes.