John Romanos

Quality of life before and after laparoscopic sleeve gastrectomy. A prospective cohort study

BACKGROUND There is a lack of adequate prospective data on quality-of-life (QOL) and its predictors in patients undergoing laparoscopic sleeve gastrectomy (LSG). The aim of this study was to assess longitudinal changes in QOL after LSG with the use of the obesity-specific Moorehead-Ardelt II questionnaire (MAII) and to identify clinical parameters associated with QOL outcome. METHODS Morbidly obese patients consecutively admitted for LSG, over a 30-month period, were prospectively studied. QOL was assessed using the validated Greek version of the MAII questionnaire and a visual analogueue scale (VAS), preoperatively and at 6, 12, and 24 months postoperatively. Anthropometric data and obesity-related co-morbidities were recorded. RESULTS A total of 111 patients with a mean age 36.8±9.2 years were included. Mean preoperative body mass index (BMI) was 49.1±7.5 kg/m2. Percentage excess BMI loss (%EBL) was 51.1±14.9, 64.2±17.9 and 66.4±18.0 at 6, 12, and 24 months, respectively. Postoperatively, all obesity-related co-morbidities were significantly improved. MAII score increased from -.40±1.30 preoperatively to 1.75±.83, 2.18±.80, and 1.95±.71 at 6, 12, and 24 months postoperatively (trend P<.001). Preoperative median (interquartile range) VAS was 3 (1) increasing to 9 (2), 10 (1), and 9 (1) at 6, 12, and 24 months postoperatively (P<.001). %EBL and reduction in obesity-related co-morbidities, especially resolution of diabetes and sleep apnea, correlated significantly with higher QOL during the course of the study. CONCLUSION LSG, a safe and effective bariatric operation, results in sustained weight loss and significant improvements in QOL. Both weight loss and amelioration of co-morbidities contribute to higher level of postsurgical QOL.

Treatment of advanced malignant eccrine poroma with locoregional chemotherapy.

Malignant eccrine poroma is a rare disease with approximately 200 cases reported in the literature. Regional cutaneous and systemic metastases are rarely observed and their management has been generally unsuccessful. We report on a case in which topical 5‐fluorouracil application and intra‐arterial chemotherapy with docetaxel resulted in a histologically confirmed complete response of multiple regional skin metastases for more than 2 years. Despite intravenous administration of docetaxel, slow progression of systemic disease was observed.

Primary psoas abscess. Report of three cases.

Abstract Background: Primary psoas abscesses are a rare clinical entity with subtle and non specific symptoms, most commonly seen in patients predisposed to infections. Early diagnosis and appropriate management are therefore challenging aspects for physicians. Patients and methods: We present three patients with primary pyogenic psoas abscess, treated at the Heraklion University Hospital, during a 5-year period. The two male and one female patient, aged 36–51 years were admitted with fever, abdominal pain and a palpable tender mass. Results: The classical sign of limping was absent in all cases. Positive psoas symptoms were detected in only two patients. CT scan accurately confirmed the diagnosis in all cases. The patients were successfully treated with antibiotics and prolonged surgical drainage. Staphylococcus aureus was the causative microorganism in the first two and Bacteroides fragilis in the third patient. This is the first reported case resulting from this specific bacteria. None of our patients had any predisposing risk factor. Conclusions: A high index of suspicion is mandatory to enable early recognition of this rare clinical disease. CT scan is the standard diagnostic tool to confirm diagnosis. Prolonged drainage and appropriate antibiotics are essential for the successful treatment of primary psoas abscesses.

Pharmacological principles of intraperitoneal and bidirectional chemotherapy

Abstract Intraperitoneal chemotherapy is associated with a significant pharmacokinetic and pharmacodynamic benefit and can, alone or in combination with systemic chemotherapy (bidirectional chemotherapy), be used for treating primary and secondary peritoneal surface malignancies. Due to the peritoneal–plasma barrier, high intraperitoneal drug concentration can be achieved by intraperitoneal chemotherapy, whereas systemic concentration remains low. Bidirectional chemotherapy may provide in addition adequate drug concentrations from the side of the subperitoneal space to the peritoneal tumour nodules. Major pharmacological problems of intraperitoneal chemotherapy are limited tissue penetration and poor homogeneity of drug distribution to the entire seroperitoneal surface. Significant pharmacological determinants of intraperitoneal chemotherapy are choice of drug, drug dosage, solution volume, carrier solution, intra-abdominal pressure, temperature, duration, mode of administration, extent of peritonectomy and interindividual variability. Drugs most commonly applied for intraperitoneal chemotherapy include mitomycin C, cisplatin, carboplatin, oxaliplatin, irinotecan, 5-fluoruracil, gemcitabine, paclitaxel, docetaxel, doxorubicin, premetrexed and melphalan. The drugs and their doses that are used vary widely among centres. While the adequate drug choice for intraperitoneal and bidirectional chemotherapy is essential, randomized clinical trials to determine the most optimal drug or drug combination are lacking, and only eight retrospective comparative clinical studies are available. Further clinical pharmacological studies are required to determine the most effective drug regimen for intraperitoneal and bidirectional chemotherapy in various indications. In the future, reliable drug sensitivity testing and genetic profiling of peritoneal metastases will be needed for enabling patient-specific therapy.

Jejunoileal Diverticulosis and Its Complications

Acquired diverticula of the jejunum and ileum are uncommon and asymptomatic in the majority of patients. They should not always be dismissed as an incidental finding, because they may be the cause of vague, chronic symptomatology. Acute complications, including intestinal obstruction, hemorrhage and perforation, are rare, but may necessitate immediate surgical intervention. Due to the relative rarity of these lesions and their complications, diagnosis is often difficult and delayed. The high mortality of the acute complications is related to delayed diagnosis and the advanced age of the patients. Four cases with complications of jejunoileal diverticulosis and three cases of asymptomatic jejunoileal diverticula are presented and the literature is reviewed.