Oscar K. Serrano

Outcomes of bariatric surgery in the young: a single-institution experience caring for patients under 21 years old

BackgroundMedical weight loss options are rarely successful long term in young patients. Bariatric surgery has been shown to be safe and effective in this population.MethodsPatients ≤21xa0years old who had bariatric surgery at our institution between January 2009 and December 2013 were evaluated to determine the safety and efficacy of bariatric surgery in this population. The primary end point was excess weight loss (EWL). Secondary end points included surgical morbidity, improvement in obesity-related metabolic parameters, and subjective obesity-related symptoms at 1xa0year.ResultsFifty-four patients were identified who had a laparoscopic Roux-en-Y gastric bypass (LGBP) or laparoscopic sleeve gastrectomy (LSG). Fourteen patients were male (25.9xa0%), and 40 patients were female (74.1xa0%). Thirty-seven patients (68.5xa0%) underwent LGBP, and 17 patients (31.5xa0%) underwent LSG. Median follow-up was 13.3xa0months. The baseline BMI was 51.7xa0kg/m2 for the LGBP group and 51.0xa0kg/m2 for the LSG group. EWL was 35.2, 47.6, 62.4, 58.1, and 61.8xa0% for the LGBP group; 29.7, 44.7, 57.4, 60.3, and 59.0xa0% for the LSG group at 3, 6, 12, 24, and 36xa0months, respectively. Our complications included 1 anastomotic bleed, 1 postoperative stricture, and 1 patient who developed vitamin deficiency that manifested as a peripheral neuropathy in the LGBP group. LGBP was more successful than LSG in improving lipid panel parameters and HbA1c at 1xa0year, and it also seemed to offer better subjective improvement in obesity-related symptoms.ConclusionsLGBP and LSG seem to confer comparable weight loss benefit in patients ≤21xa0years old with acceptable surgical morbidity.

Weight loss outcomes and complications from bariatric surgery in the super super obese

BackgroundBariatric surgery has been established as the most effective long-term treatment for morbid obesity.MethodsWe performed a retrospective review of SSO patients treated at our institute between 2008 and 2013 who underwent a laparoscopic gastric bypass (LGBP) or sleeve gastrectomy (LSG). The primary end point for this study was excess weight loss (EWL) at 1, 3, 6, and 12xa0months. Secondary end points included procedure length (PL), length of stay (LOS), diabetes management and postoperative complications.ResultsWe identified 135 SSO patients who underwent bariatric surgery (93 LGBP, 42 LSG) at our institute from 2008 to 2013 with a median follow-up of 49xa0months. The incidence of EWLxa0>xa030xa0% for patients in the LGBP group was 3.9, 29.0, 72.2 and 94.6xa0% at 1, 3, 6 and 12xa0months, respectively, while the incidence of EWLxa0>xa030xa0% in patients in the LSG group was 4.2, 25.0, 59.1 and 100xa0% at 1, 3, 6 and 12xa0months, respectively. PL was 124xa0±xa049xa0min for the LGBP group and 98xa0+xa051xa0min for the LSG group (pxa0<xa00.005). LOS was on average 3.0xa0days (range 1–21) for the LGBP group and 3.4xa0days (range 1–13) for the LSG group (pxa0=xa00.41). Patients experienced a decrease in their hemoglobin A1C level by 10xa0% for the LGBP group and 9xa0% for the LSG group at 1xa0year (pxa0=xa00.89). Postoperative complications were seen in 15.1xa0% of LGBP patients and 4.8xa0% of LSG patients.ConclusionsBariatric surgery is feasible in the SSO patients with comparable EWL outcomes and postoperative complications to historical non-SSO patients.

Antitumor effect of pharmacologic ascorbate in the B16 murine melanoma model

Because 5-year survival rates for patients with metastatic melanoma remain below 25%, there is continued need for new therapeutic approaches. For some tumors, pharmacologic ascorbate treatment may have a beneficial antitumor effect and may work synergistically with standard chemotherapeutics. To investigate this possibility in melanoma, we examined the effect of pharmacologic ascorbate on B16-F10 cells. Murine models were employed to compare tumor size following treatment with ascorbate, and the chemotherapeutic agents dacarbazine or valproic acid, alone or in combination with ascorbate. Results indicated that nearly all melanoma cell lines were susceptible to ascorbate-mediated cytotoxicity. Compared to saline controls, pharmacologic ascorbate decreased tumor size in both C57BL/6 (P < 0.0001) and NOD-scid tumor bearing mice (P < 0.0001). Pharmacologic ascorbate was superior or equivalent to dacarbazine as an antitumor agent. Synergy was not apparent when ascorbate was combined with either dacarbazine or valproic acid; the latter combination may have additional toxicities. Pharmacologic ascorbate induced DNA damage in melanoma cells, as evidenced by increased phosphorylation of the histone variant, H2A.X. Differences were not evident in tumor samples from C57BL/6 mice treated with pharmacologic ascorbate compared to tumors from saline-treated controls. Together, these results suggest that pharmacologic ascorbate has a cytotoxic effect against melanoma that is largely independent of lymphocytic immune functions and that continued investigation of pharmacologic ascorbate in cancer treatment is warranted.

Excess Weight Loss and Cardiometabolic Parameter Reduction Diminished among Hispanics Undergoing Bariatric Surgery: Outcomes in More than 2,000 Consecutive Hispanic Patients at a Single Institution

BACKGROUNDnBariatric surgery has been established as the most effective long-term treatment for morbid obesity and obesity-related comorbidities. Despite its success, there is a paucity of data on the outcomes of bariatric surgery on Hispanic patients.nnnSTUDY DESIGNnWe performed a retrospective review of obese patients treated at our institute between 2008 and 2014. We identified self-reported Hispanic patients who underwent a laparoscopic gastric bypass (LGBP), sleeve gastrectomy (LSG), or gastric band (LGB) procedure. The primary end point was excess weight loss (EWL) at 6, 12, 24, and 36 months. Secondary end points included improvement of obesity-related metabolic parameters at 1 year. We performed a repeated measures analysis of variance to calculate statistical significance throughout our study time period.nnnRESULTSnWe identified 2002 Hispanic patients who underwent bariatric surgery (1,235 LGBP, 600 LSG, 167 LGB) at our institute from 2008 to 2014. Follow-ups at 6, 12, 24, and 36 months were 62.2%, 54.5%, 36.2%, and 19.8%, respectively. Mean preoperative BMIs were 47.0 ± 7.2 kg/m2, 46.1 ± 7.8 kg/m2, and 44.9 ± 6.0 kg/m2 for the LGBP, LSG, and LGB cohorts, respectively. Excess weight loss was significantly more pronounced in the LGBP and the LSG groups than in the LGB group; this difference was accentuated over time (p < 0.0001). Obesity-related metabolic parameters and the need for comorbidity medical therapy decreased in all 3 surgical groups.nnnCONCLUSIONSnBariatric surgery is highly successful in Hispanic obese patients. In the largest series to date, LGBP and LSG seem to yield more effective EWL and reduction of cardiometabolic parameters than LGB among Hispanics; however, outcomes are still markedly reduced when compared with those in non-Hispanic populations.

Correlation between preoperative endoscopic ultrasound and surgical pathology staging of gastric adenocarcinoma: A single institution retrospective review

Recent evidence validates the effectiveness of neoadjuvant chemotherapy in the treatment of gastric adenocarcinoma. Endoscopic ultrasonographic (EUS) staging has been proposed as a useful adjunct in this setting.

An intraoperative technique to reduce superficial surgical site infections in circular stapler-constructed laparoscopic Roux-en-Y gastric bypass

BACKGROUNDnLaparoscopic Roux-en-Y gastric bypass (LRYGB) has been established as one of the most effective treatments for morbid obesity. Surgical site infections are the most common complication after LRYGB surgery.nnnOBJECTIVEnTo compare the superficial surgical site infections (sSSI) rate before and after the implementation of our intraoperative technique.nnnSETTINGnAcademic medical center.nnnMETHODSnOur intraoperative technique relies on sterile coverage of the circular stapler, sterile specimen-bag retrieval of the gastrojejunostomy enteric remnant, and port site Penrose drainage. We analyzed our sSSI outcomes before and after implementation of our technique in all LRYGBs performed by a single surgeon from 2009 to 2015. We took into account patient age; sex; baseline body mass index (BMI); smoking status; and co-morbidities such as diabetes, hypertension, and hyperlipidemia. χ(2) and multivariate analysis were performed.nnnRESULTSnWe performed 486 LRYGBs in 2009-2015. The cohort before implementation of our technique (group 1) included 164 patients (33.7%) and the cohort after implementation (group 2) included 322 patients (66.3%). Both groups were similar in age, sex, smoking status, and rates of diabetes and hyperlipidemia but differed in BMI, operative time, and prevalence of hypertension. Hypertension was not a confounder for sSSI (P = .35). The sSSI rate was 9.15% for group 1 and 3.42% for group 2 (P = .0079). Controlling for BMI and operative time, multivariate analysis revealed a significant reduction in sSSI (odds ratio 2.98 [95% CI 1.33-6.69]) with our technique.nnnCONCLUSIONSnWe describe a reproducible intraoperative technique that significantly reduces sSSI in LRYGB procedures. Our technique has the potential of hastening postoperative recovery.

Pediatric primary splenic angiosarcoma: an aggressive multidisciplinary approach to the oncologic management of a rare malignancy

Primary splenic angiosarcoma is an extremely rare and aggressive neoplasm of the vasculature. Uniformly, primary splenic angiosarcoma is a fatal disease despite early diagnosis and treatment. Only patients with localized disease amenable to surgical resection achieve long-term, disease-free survival. We present a review of the literature and report a case of a 3-year-old girl with metastatic primary splenic angiosarcoma who was offered aggressive surgical and medical treatment with curative intent despite her advanced presentation.

Diarrhea, Weight Loss, and an Ampullary Mass

Aman in his 50swith a history of hypercholesterolemia and type 2 diabetesmellitus was referred for diarrhea (5-6 timesperday) anda27-kgweight loss in thepreceding5months. The patient did not have abdominal pain, nausea, vomiting, or a history of abdominal surgical procedures and did not use alcohol or tobacco. On physical examination, the patient’s abdomen was soft, nontender, and nondistended, with no palpable masses, and he did not appear jaundiced. Results of laboratory testing demonstrated a carbohydrate antigen 19-9 level of less than 1 U/mL and a carcinoembryonic antigen level of 6.0 ng/mL (to convert tomicrograms per liter, multiply by 1.0). Aduodenalmasswas foundusingesophagogastroduodenoscopyandbiopsieswere taken. To further evaluate the lesion, thepatient underwent a computed tomographic scanof the abdomen and pelvis with contrast dye (Figure 1). A B