Gianetta E

Pregnancies in an 18-Year Follow-up after Biliopancreatic Diversion

Background: 239 pregnancies occurred in 1136 women who had undergone biliopancreatic diversion (BPD). Methods: There were 73 abortions, and 14 pregnancies are presently in their course. The 152 term pregnancies (six twins) occurred in 129 women 2-173 months (mean 42.7) after BPD. Mean age and current excess weight were 31.4 years (20-42) and 29.1% (-6.9-78.2), and mean excess weight loss was 72.9% (30.4-110.5). Results: Mean weight gain during pregnancy was 6.2 kg (-21-25). In 32 patients (21%), parenteral nutritional support was needed. In all the other patients (79%), the usual supplementations were given. Of the newborns, 122 were delivered at term (84.7%) with a mean weight of 2842.4 g (1760-4600 g) and a mean length of 48.5 cm (43-59 cm), while the 22 preterm babies (15.3%) weighed 2151.1 g (1400-3850 g) and had a length of 44.6 cm (33-56 cm). Forty infants (27.8%) were small for gestational age but 17 of them weighed more than 2500 g. Eleven twins (one abortion at 26th week) were also delivered, with a mean weight of 2088.6 g (1200-3100 g) and a mean length of 45.6 cm (35-50 cm). Delivery was spontaneous in 85 instances (56%), while vacuum extractor was used in one, and 66 cesarean sections were performed. There were two birth malformations, one infant died after surgery for meconium obstruction and two died from unknown causes. Of the 129 women, 35 had been infertile before BPD. Conclusions: Disappearance of infertility and decrease of pregnancy risk are to be considered among the beneficial effects of weight reduction following BPD.

Protein-energy wasting and mortality in chronic kidney disease.

Protein-energy wasting (PEW) is common in patients with chronic kidney disease (CKD) and is associated with an increased death risk from cardiovascular diseases. However, while even minor renal dysfunction is an independent predictor of adverse cardiovascular prognosis, PEW becomes clinically manifest at an advanced stage, early before or during the dialytic stage. Mechanisms causing loss of muscle protein and fat are complex and not always associated with anorexia, but are linked to several abnormalities that stimulate protein degradation and/or decrease protein synthesis. In addition, data from experimental CKD indicate that uremia specifically blunts the regenerative potential in skeletal muscle, by acting on muscle stem cells. In this discussion recent findings regarding the mechanisms responsible for malnutrition and the increase in cardiovascular risk in CKD patients are discussed. During the course of CKD, the loss of kidney excretory and metabolic functions proceed together with the activation of pathways of endothelial damage, inflammation, acidosis, alterations in insulin signaling and anorexia which are likely to orchestrate net protein catabolism and the PEW syndrome.

Anterior tension-free repair of recurrent inguinal hernia under local anesthesia: a 7-year experience in a teaching hospital.

OBJECTIVE To describe a 7-year experience with recurrent inguinal hernia repair performed mainly with tension-free mesh or plug technique under local anesthesia through the anterior approach, and to evaluate the safety and effectiveness of this method of treatment. METHODS One hundred forty-five elective and 1 emergency herniorrhaphies for recurrent groin hernia were performed in 141 subjects (134 men and 7 women) with a mean age of 65 years (range 30-89). Concomitant medical and surgical problems were present in 73% and 8% of subjects, respectively. In 28 instances, the relapsed hernia had already been operated on once or twice for recurrence. A traditional hernioplasty had been previously performed in the vast majority of cases (136). Tension-free mesh or plug techniques through an anterior approach under local anesthesia were performed in 144 reoperations. Preperitoneal mesh repair and general or spinal anesthesia were used in all but one case when herniorrhaphy was performed during simultaneous operations. RESULTS Mean hospital stay after surgery was 1.5 days (range 3 hours-14 days). No perioperative deaths occurred in this series. General complications were one case of acute intestinal bleeding and two cases of urinary retention. Local complications consisted of eight (5.5%) minor complications and one case of orchitis (0.7%) followed by testicular atrophy. In no instance was postoperative neuralgia or chronic pain reported. Two re-recurrences occurred. CONCLUSIONS Given the low complication rate in this and other reported series and the absence of surgical or general complications described after preperitoneal open or laparoscopic repair and after general and spinal anesthesia, anterior mesh repair under local anesthesia seems to be a low-cost surgical technique that can be safely and effectively used even in a teaching hospital for the treatment of the majority of patients with recurrent groin hernias.

APPENDECTOMY OR RIGHT HEMICOLECTOMY IN THE TREATMENT OF APPENDICEAL CARCINOID TUMORS

Aims and background Carcinoids of the appendix continue to be of interest, despite their low incidence. There is still considerable controversy surrounding these tumors, especially with regard to the role of right hemicolectomy in the surgical management. The aim of this work was to explicate the current therapeutic knowledge and to review the criteria for the indications of appendectomy or hemicolectomy. Methods The records of patients who underwent appendectomies from 1990 to 2000 were analyzed. Seven patients were included in the study. The clinical data were reviewed for demographic details, tumor size, localization in the appendix, histological patterns and surgical procedures. All patients underwent appendectomy including removal of the mesenteriolum, and in one of them a right hemicolectomy was performed 3 weeks later. The mean follow-up was 7 years (range, 4–14). Follow-up data included symptoms, urinary 5-hydroxyin-doleacetic acid, ultrasound examination, computerized tomography, and octreotide scanning. Results Seven patients (0.9% of all appendectomies) were reported to have carcinoid tumors of the appendix. They were 3 men and 4 women with a mean age of 29 years. All patients were admitted for appendicitis. None suffered from the carcinoid syndrome. The site of the tumor was the apex of the appendix in 4 cases, the body in 2 cases and the base in 1 case. Mean tumor diameter was 8 mm (range, 5–29 mm); in 6 patients it was <2 cm. Treatment was appendectomy in all cases; additional right hemicolectomy was necessary in one case because of a tumor of more than 2 cm with invasion of the mesoappendix and lymph nodes. The 7-year survival rate is 100%. Six patients are without disease, while 1 patient (the one who underwent a right hemicolectomy) developed metastases in the liver 6 years after the operation. This patient, who was treated with a liver resection, is still alive. Conclusions According to current guidelines, an appendectomy may be performed for small carcinoid tumors (<1 cm). Reasons for more extensive surgery than appendectomy are tumor size >2 cm, lymphatic invasion, lymph node involvement, spread to the mesoappendix, tumor-positive resection margins, and cellular pleomorphism with a high mitotic index. The criteria that direct us towards major (hemicolectomy) or minor surgery (appendectomy) are controversial. Tumor size is still considered the most important prognostic factor, with a presumed increase in the risk of metastasis for tumors greater than 2.0 cm. The accepted treatment of such tumors is a right hemicolectomy. However, there is no evidence demonstrating a survival benefit for right hemicolectomy over simple appendectomy in patients with carcinoids greater than 2.0 cm in diameter.

Wernicke-Korsakoff Encephalopathy Following Biliopancreatic Diversion

Wernicke-Korsakoff disease with sensory-motor neuropathy was diagnosed in three out of a series of 1663 patients (0.18%), with onset 2, 3 and 5 months after biliopancreatic diversion. Precipitating factors were vomiting, minimal food intake, anorexia, rapid weight loss, and glucose-containing intravenous feeding. Recovery was partial in two and complete in one of the patients. In the early postop, prophylactic thiamine should be given to the patients with excessively limited eating capacity. Larger doses of thiamine should be instituted parenterally either in the case of suspected Wernicke-Korsakoff encephalopathy or before starting feeding for protein malnutrition.

Apoptosis and myostatin mRNA are upregulated in the skeletal muscle of patients with chronic kidney disease

Apoptosis and myostatin are major mediators of muscle atrophy and might therefore be involved in the wasting of uremia. To examine whether they are expressed in the skeletal muscle of patients with chronic kidney disease (CKD), we measured muscle apoptosis and myostatin mRNA and their related intracellular signal pathways in rectus abdominis biopsies obtained from 22 consecutive patients with stage 5 CKD scheduled for peritoneal dialysis. Apoptotic loss of myonuclei, determined by anti-single-stranded DNA antibody and terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling assays, was significantly increased three to fivefold, respectively. Additionally, myostatin and interleukin (IL)-6 gene expressions were significantly upregulated, whereas insulin-like growth factor-I mRNA was significantly lower than in controls. Phosphorylated JNK (c-Jun amino-terminal kinase) and its downstream effector, phospho-c-Jun, were significantly upregulated, whereas phospho-Akt was markedly downregulated. Multivariate analysis models showed that phospho-Akt and IL-6 contributed individually and significantly to the prediction of apoptosis and myostatin gene expression, respectively. Thus, our study found activation of multiple pathways that promote muscle atrophy in the skeletal muscle of patients with CKD. These pathways appear to be associated with different intracellular signals, and are likely differently regulated in patients with CKD.

Hair and plasma zinc levels following exclusion of biliopancreatic secretions from functioning gastrointestinal tract in humans

Pancreatic secretions have been shown to be important in zinc absorption in experimental animals. Recently, complete surgical diversion of biliary and pancreatic secretions from the functioning small intestine has been utilized in Europe to treat morbid obesity. To determine the importance of pancreatic secretions in zinc absorption in the human, we measured hair and serum zinc levels in 14 patients having undergone complete biliopancreatic bypass 12–56 months earlier and compared these values with those obtained from 11 patients subjected to only partial biliopancreatic bypass as well as to six morbidly obese controls. No differences were observed in either hair or serum zinc levels between any of these groups of patients. Pancreatic secretions do not appear to be necessary for adequate zinc absorption in humans.

Preoperative Eating Behavior and Weight-loss Following Gastric Banding for Obesity

Background and Methods: The relationships between cognitive restraint and the tendency to disinhibition, as assessed by the Three Factor Eating Questionnaire (TFEQ), and the weight loss at 1 year following gastric banding were evaluated. Results: A significant predictability of the TFEQ Disinhibition score on the postoperative weight reduction was observed, while the amount of weight lost was negatively related to the preoperative TFEQ Cognitive Restraint score. Conclusion: It must then be hypothesized that the operated subjects feel a strong aversive stimulus and then they are led to reduce their food consumption only when they lose control and tend to overeat. The discomfort due to proximal gastric pouch distension facilitates the development of food aversion and then both the decrease of food intake and a change in eating behavior. The subjects must therefore be encouraged to adopt an eating style that cannot allow them to avoid such a feeling.

Laparoscopic bridging vs. anatomic open reconstruction for midline abdominal hernia mesh repair [LABOR]: single-blinded, multicenter, randomized, controlled trial on long-term functional results

BackgroundRe-approximation of the rectal muscles along the midline is recommended by some groups as a rule for incisional and ventral hernia repairs. The introduction of laparoscopic repair has generated a debate because it is not aimed at restoring abdominal wall integrity but instead aims just to bridge the defect. Whether restoration of the abdominal integrity has a real impact on patient mobility is questionable, and the available literature provides no definitive answer. The present study aims to compare the functional results of laparoscopic bridging with those of re-approximation of the rectal muscle in the midline as a mesh repair for ventral and incisional abdominal defect through an “open” access. We hypothesized that, for the type of defect suitable for a laparoscopic bridging, the effect of an anatomical reconstruction is near negligible, thus not a fixed rule.Methods and designThe LABOR trial is a multicenter, prospective, two-arm, single-blinded, randomized trial. Patients of more than 60 years of age with a defect of less than 10 cm at its greatest diameter will be randomly submitted to open Rives or laparoscopic defect repair. All the participating patients will have a preoperative evaluation of their abdominal wall strength and mobility along with volumetry, respiratory function test, intraabdominal pressure and quality of life assessment.The primary outcome will be the difference in abdominal wall strength as measured by a double leg-lowering test performed at 12 months postoperatively. The secondary outcomes will be the rate of recurrence and changes in baseline abdominal mobility, respiratory function tests, intraabdominal pressure, CT volumetry and quality of life at 6 and 12 months postoperatively.DiscussionThe study will help to define the most suitable treatment for small-medium incisional and primary hernias in patients older than 60 years. Given a similar mid-term recurrence rate in both groups, if the trial shows no differences among treatments (acceptance of the null-hypothesis), then the choice of whether to submit a patient to one intervention will be made on the basis of cost and the surgeon’s experience.Trial registrationCurrent Controlled Trials ISRCTN93729016

Pseudodiverticular defecographic image after STARR procedure for outlet obstruction syndrome

Dear Editor: Outlet obstruction syndrome (OOS) is a defecation disorder more common in women. Patients refer to coloproctologists complaining of constipation and other typical symptoms ranging from incomplete and fragmentized evacuation to rectal bleeding. This syndrome may be caused by functional and/or anatomical alterations. A correct etiological classification can help the clinician to predict the best treatment strategy. Non-operative treatment, mainly based on dietary changes and biofeedback, is usually suggested as the first or unique treatment option when symptoms are caused by an uncoordinated inhibitory muscular pattern. Conversely, patients not responsive to conservative treatment most likely can benefit from surgery. Nevertheless, traditional techniques, aimed at restoring normal anatomy, are often time-consuming, technically demanding, burdened by serious complications, and, sometimes, under particular circumstances, can be ineffective or can even worsen symptoms. In 2003 Stapled Transanal Rectal Resection (STARR) was described by Longo as an effective new option for the cure of OOS. Since its introduction, STARR has become an accepted surgical procedure even if some criticisms have been raised due to possible serious complications. Recently, a case of rectal diverticulum after STARR procedure has been reported. Here, we describe a similar case, its related diagnostic and treatment modalities. A 60-year-old woman, who had previously undergone unsuccessful medical treatment, was submitted to STARR in our service for obstructed defecation syndrome caused by an anterior and posterior rectocele associated with a posterior rectal wall prolapse. The technique, described elsewhere, follows the same steps as standardized by Longo. In the present case, at the end of the procedure, the stapled line was carefully inspected. As routinely performed, the mucosal band connecting the two edges of the anastomosis was cut both anteriorly and posteriorly. Stitches were then applied at the anastomotic level in order to avoid the risk of postoperative bleeding. The postoperative course was uneventful, and patient discharged on the third postoperative day. One month later, the patient presented at our outpatient visit complaining of recurrence of symptoms with tenesmus, constipation, a sensation of incomplete evacuation, painful and unsuccessful efforts, urge to defecate, anal incontinence, with need of digital assistance. Defecography showed a diverticular cavity on the right rectal wall (60 mm diameter) and an incomplete evacuation of barium. This lateral diverticulum, filled up by impacted stools, shrank the rectal pouch lumen during straining and defecation. The patient refused clinical examination and endoscopy because of intense pain and an examination under spinal anesthesia was then planned. The exam revealed the presence of a bridge of rectal mucosa, 2 cm wide, on the posterior wall. This bridge caused deformation of the rectal profile creating a diverticular cavity full of impacted stools. After mechanical emptying of the diverticulum the mucosal bend was cut with restoration of normal anatomy. Two months after this procedure, the patient had significantly improved defecation with complete resolution of symptoms. Defecography, performed 3 months postopInt J Colorectal Dis (2009) 24:1115–1116 DOI 10.1007/s00384-009-0666-6