Gitana Scozzari

Esophagogastric cancer after bariatric surgery: systematic review of the literature

BACKGROUND Because the number of patients with a previous bariatric procedure continues to rise, it is advisable for bariatric surgeons to know how to manage the rare event of the development of an esophagogastric cancer. The aim of the study was to perform a systematic review of all reported cases of esophagogastric cancers after bariatric surgery. METHODS Systematic review of English and French written literature in MEDLINE and EMBASE database. RESULTS Globally, 28 articles describing 33 patients were retrieved. Neoplasms were diagnosed at a mean of 8.5 years after bariatric surgery (range 2 months-29 years). There were 11 esophageal and 22 gastric cancers; although adenocarcinoma represented most cases (90.6%), a tubulovillous adenoma with high-grade atypia, an intramural gastrointestinal stromal tumor, and a diffuse large B-cell lymphoma of the gastric fundus were also reported. Node involvement was reported in 14 cases, and distal metastases in 5. The most frequently reported symptoms were dysphagia and food intolerance, vomiting, epigastric pain, and weight loss. Surgery was performed in 28 patients, although 4 underwent only chemotherapy and/or radiotherapy and 1 received palliative care. Reported mortality rate was 48.1%. CONCLUSIONS To date, it is not possible to quantify the incidence of esophagogastric cancer after bariatric surgery because of the paucity of reported data. Nevertheless, because the main concern is the delay in diagnosis, it is of critical importance to carefully evaluate any new or modified upper digestive tract symptom occurring during bariatric surgery follow-up.

Age as a long-term prognostic factor in bariatric surgery.

Objective:To analyze the potential effects of preoperative age on postoperative weight loss in patients who underwent Roux-en-Y gastric bypass (RYGBP) with long-term follow-up data. Background:The reasons for individual differences in surgically induced weight loss are not completely understood. To date, there are no available studies specifically aimed at analyzing the effects of age on weight loss in patients undergoing the same operation and with long-term follow-up data. Methods:Retrospective analysis of prospectively collected data for all patients who underwent RYGBP between 2006 and 2010. To evaluate weight loss, we used preoperative and follow-up body mass index (BMI), analyzed by the mixed-effects linear model for repeated measures. To evaluate age effects, patients were classified in quartiles (⩽35 years, 36–42 years, 43–51 years, ≥52 years). Results:A total of 489 patients entered the study; preoperatively, the younger group showed a significantly higher BMI (mean BMI: 48.2 in patients aged ⩽35 years, 46.9 in 36–42 years, 45.5 in 43–51 years, 45.7 in ≥52 years, P = 0.014) and a higher percentage of super-obesity (41.6% among patients aged ⩽35 years, 28.1% among 36–42 years, 27.6% among 43–51 years, 28.3% among ≥ 52 years, P = 0.047). In spite of this, younger patients experienced a significantly greater and prolonged BMI decrease during the entire follow-up period and the BMI trend over time resulted significantly modified according to age quartiles (P = 0.036). Conclusions:This study provides a new prognostic factor in bariatric surgery: patient age. Because advanced age represents a risk factor for complications and mortality, and given that bariatric surgery may not be as effective in older patients compared to younger subjects, we believe that surgical indications in patients older than 50 years should be carefully weighed up.

Gastroesophageal reflux disease and laparoscopic sleeve gastrectomy: a physiopathologic evaluation.

Objective:To evaluate the effect of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) in morbidly obese patients. Background:Symptomatic GERD is considered by many a contraindication to LSG. However, studies evaluating the relationship between LSG and GERD by 24-hour pH monitoring are lacking. Methods:Consecutive morbidly obese patients selected for LSG were included in a prospective clinical study. Gastroesophageal function was evaluated using a clinical validated questionnaire, upper endoscopy, esophageal manometry, and 24-hour pH monitoring before and 24 months after LSG. This trial is registered with ClinicalTrials.gov (no. NCT02012894). Results:From June 2009 to September 2011, a total of 71 patients were enrolled into the study; 65 (91.5%) completed the 2-year protocol. On the basis of preoperative 24-hour pH monitoring, patients were divided into group A (pathologic, n = 28) and group B (normal, n = 37). Symptoms improved in group A, with the Gastroesophageal Reflux Disease Symptom Assessment Scale score decreasing from 53.1 ± 10.5 to 13.1 ±3.5 (P < 0.001). The DeMeester score and total acid exposure (% pH <4) decreased in group A patients (DeMeester score from 39.5 ± 16.5 to 10.6 ± 5.8, P < 0.001; % pH <4 from 10.2 ± 3.7 to 4.2 ± 2.6, P < 0.001). Real “de novo” GERD occurred in 5.4% group B patients. No significant changes in lower esophageal sphincter pressure and esophageal peristalsis amplitude were found in both groups. Conclusions:LSG improves symptoms and controls reflux in most morbidly obese patients with preoperative GERD. In obese patients without preoperative evidence of GERD, the occurrence of “de novo” reflux is uncommon. Therefore, LSG should be considered an effective option for the surgical treatment of obese patients with GERD.

Enterovesical fistulas: diagnosis and management

Enterovesical fistula (EVF) is an abnormal communication between the intestine and the bladder. It represents a rare complication of inflammatory or neoplastic disease, and traumatic or iatrogenic injuries. The most common aetiologies are diverticular disease and colorectal carcinoma. Over 75% of affected patients describe pathognomonic features of pneumaturia, faecaluria and recurrent urinary tract infections. The diagnosis of EVF can be challenging, and frequently patients are monitored for months before the condition is recognised and treated effectively. Diagnostic tools include laboratory tests, imaging studies and endoscopic procedures. Although conservative management can be attempted in selected patients, in most cases, the treatment is mainly based on surgical interventions. Recently, the laparoscopic approach to EVF has been shown to be safe and effective. Although it is a rare condition in a general surgery setting, EVF is a challenging condition leading to high morbidity and mortality rates.

10-year follow-up of laparoscopic vertical banded gastroplasty. Good results in selected patients

Objective:To evaluate the long-term results of laparoscopic vertical banded gastroplasty (VBG) for morbid obesity. Background:Laparoscopic VBG, a safe and straightforward bariatric procedure characterized by good short-term results, has been progressively replaced by other more complex procedures on the basis of a presumed high rate of long-term failure. Nevertheless, some authors have recently reported long-term efficacy in selected patients. Methods:All patients who underwent laparoscopic VBG were included in a prospective database. Patients reaching 10-year follow-up received a complete evaluation including clinical, endoscopic, and biochemical examinations. Results:Between January 1996 and March 1999, 266 morbidly obese patients underwent bariatric procedures. Among them, 213 were selected for laparoscopic VBG; exclusion criteria were as follows: contraindications to pneumoperitoneum, gastroesophageal reflux disease, and psychological contraindications to restrictive procedures. Mean age, preoperative weight, and body mass index were 36.9 years, 123.6 kg, and 45.4 kg/m2, respectively. Intraoperative complication rate and conversion rate were 0.9% and 0.9%, respectively. Early postoperative complication rate was 4.2% and early reoperation rate was 0.5%. Mean hospital length of stay was 6.3 days. Mortality was nil. The 10-year follow-up rate was 70.4% (150 patients). Late postoperative complication rate was 14.7%, and 10-year revisional surgery rate was 10.0%. The excess weight loss percentages at 3, 5, and 10 years were 65.0%, 59.9%, and 59.8%, respectively. The resolution and/or improvement rate for comorbidity were 47.5% for hypertension, 55.6% for diabetes, 75% for sleep apnea, and 47.4% for arthritis. Mean Moorehead-Ardelt Quality of Life Questionnaire and BAROS values were 1.4 and 3.8, respectively. Conclusions:The present study demonstrates that laparoscopic VBG in carefully selected patients leads to long-term results comparable with more complex and invasive procedures. Given the low postoperative morbidity for laparoscopic VBG, its present clinical role should be, in our opinion, reevaluated.

Warm ischemia‐reperfusion injury is decreased by tacrolimus in steatotic rat liver

Ischemia‐reperfusion (I‐R) injury is poorly tolerated by fatty livers, most probably secondary to reduced cellular adenosine triphosphate (ATP) levels. We investigated the effectiveness of tacrolimus pretreatment on fatty liver I‐R injury in obese Zucker rats. Tacrolimus (0.3 mg/kg, intravenously) was injected 24 hours before a 75‐minute ischemic period and rats were sacrificed 6 hours later. Tacrolimus modified the response to I‐R observed in obese Zucker rats, when compared to nontreated obese rats: a significant reduction in hepatocyte necrosis was associated with a significant increase in hepatocyte apoptosis. In addition, cell necrosis and apoptosis were significantly and inversely correlated in lean nontreated and treated obese Zucker rats following I‐R. Tacrolimus also significantly increased the hepatic ATP levels, reduced in nontreated obese rats, toward values found in lean Zucker rat livers. This protective effect of tacrolimus was further confirmed in vivo by a significantly improved survival following pretreatment with tacrolimus, 24 hours prior to ischemia. In conclusion, in obese Zucker rat livers, tacrolimus pretreatment reversed the I‐R injury toward the one found in lean Zucker rats. The correlations between ATP levels and the opposite changes in necrosis and apoptotic pathways strongly suggest a cause‐effect relationship between tacrolimus and changes in ATP levels. Liver Transpl 12:217–225, 2006.

Obese Women’s Perception of Bariatric Trans-vaginal NOTES

Much of the discussion pertaining to natural orifice transluminal endoscopic surgery (NOTES) focuses on technical issues, with little attention to women’s perception and to their willingness to consent to this surgery, especially in the field of obesity. Aim of this study was to evaluate obese women’s perception of NOTES and trans-vaginal access. Sixty two obese patients undergoing bariatric surgery were given a written description of NOTES with an anonymous questionnaire exploring their concerns and opinions regarding this technique. The risk of complications was the most important aspect with regard to surgical procedures for 87.1% of patients, while the aesthetic result counted only for 16.1%; none of the patients would accept an increased risk of surgical complications for a better aesthetic result, and 74.2% of them would prefer a standardized traditional surgical approach. Nulliparous women were more concerned about the potentially negative effects of NOTES on fertility than multiparous women and younger women were more worried about the effects on sexual function than older women. 83.9% of patients refusing NOTES stated that the main reason for their refusal was the lack of definitive data on the beneficial effects. Bariatric NOTES potentially offers obese women a scarless intervention, but only a few obese women expressed worries about the cosmetic/aesthetic effects of surgery, while most of them were worried about effects on future fertility and sexual life. Our study highlights a strong need for early reporting of outcome data to enlighten patients about this new approach to bariatric surgery.

Perianal granular cell tumor: report of a case and review of the literature

INTRODUCTION Granular cell tumor was first described by Abrikossoff in 1926. Over the years several cases of this neoplasm have been reported, with a variety of localizations. We here report a case of perianal granular cell tumor and discuss its histogenesis and its relevance to clinical practice. METHODS The clinical course and histopathology of the case are reviewed, and a literature search for other reported cases has been performed. RESULTS A 46-year-old woman presented with a perianal nodular lesion. Pathological examination revealed a granular cell tumor. A literature search produced only 25 other cases of anal and perianal granular cell tumors. CONCLUSIONS Granular cell tumors are rarely observed in the perianal region. Their existence must always be borne in mind in the differential diagnosis of perianal neoplasms. In most cases surgical excision is curative, but potential malignant transformation must be considered during therapeutic procedures and follow-up.

Laparoscopy for extraperitoneal rectal cancer reduces short-term morbidity: Results of a systematic review and meta-analysis

Background The role of laparoscopy in the treatment of extraperitoneal rectal cancer is still controversial. The aim of the study was to evaluate differences in safety of laparoscopic rectal resection for extraperitoneal cancer, compared with open surgery. Materials and methods A systematic review from 2000 to July 2012 was performed searching the MEDLINE and EMBASE databases (PROSPERO registration number CRD42012002406). We included randomized and prospective controlled clinical studies comparing laparoscopic and open resection for rectal cancer. Primary endpoints were 30-day mortality and morbidity. Then a meta-analysis was conducted by a fixed-effect model, performing a sensitivity analysis by a random-effect model. Relative risk (RR) was used as an indicator of treatment effect. Results Eleven studies, representing 1684 patients, met the inclusion criteria: four were randomized for a total of 814 patients. Mortality was observed in 1.2% of patients in the laparoscopic group and in 2.3% of patients in the open group, with an RR of 0.56 (95% CI 0.19–1.64, p = 0.287). The overall incidence of short-term complications was lower in the laparoscopic group (31.5%) compared to the open group (38.2%), with an RR of 0.83 (95% CI 0.73–0.94, p = 0.004). Surgical complications, wound complications, blood loss and the need for blood transfusion, time for bowel movement recovery, food intake recovery, and hospital stay were significantly lower or less frequent in the laparoscopic group. The incidence of intra-operative injuries, anastomotic leakages, and surgical re-interventions was similar in the two groups. Only operative time was in favour of the open group. Conclusions Based on the evidence of both randomized and prospective controlled series, mortality was lower after laparoscopy although not significantly so, while the short-term morbidity RR, including subgroup analysis, was significantly lower after laparoscopy for extraperitoneal rectal cancer compared to open surgery.

YouTube®: An ally or an enemy in the promotion of living donor kidney transplantation?

The aim of the study is to evaluate the availability and accuracy of the existing Italian-language medical information about living donor kidney transplantation on YouTube®. For each video, several data were collected, and each video was classified as “useful,” “moderately useful” and “not useful.” Globally, the search resulted in 306 videos: 260 were excluded and 46 included in the analysis. The main message conveyed by the video was positive in 28 cases (60.9%), neutral in 16 (34.8%) and negative in 2 (4.4%). The mean amount of visualizations was 3103.5 (range: 17–90,133) and the mean amount of “likes” 2.7 (range: 0–28). Seven videos (15.2%) were classified as “useful,” 21 (45.7%) as “moderately useful” and 18 (39.1%) as “not useful.” This study showed that a very few videos in Italian about living donor kidney transplantation are available on YouTube, with only 15 percent of them containing useful information for the general population.