Tom Mala

Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch

BACKGROUND Bariatric surgery is widely performed to induce weight loss. OBJECTIVE The objective was to examine changes in vitamin status after 2 bariatric surgical techniques. DESIGN A randomized controlled trial was conducted in 2 Scandinavian hospitals. The subjects were 60 superobese patients [body mass index (BMI; in kg/m(2)): 50-60]. The surgical interventions were either laparoscopic Roux-en-Y gastric bypass or laparoscopic biliopancreatic diversion with duodenal switch. All patients received multivitamins, iron, calcium, and vitamin D supplements. Gastric bypass patients also received a vitamin B-12 substitute. The patients were examined before surgery and 6 wk, 6 mo, and 1 y after surgery. RESULTS Of 60 surgically treated patients, 59 completed the follow-up. After surgery, duodenal switch patients had lower mean vitamin A and 25-hydroxyvitamin D concentrations and a steeper decline in thiamine concentrations than did the gastric bypass patients. Other vitamins (riboflavin, vitamin B-6, vitamin C, and vitamin E adjusted for serum lipids) did not change differently in the surgical groups, and concentrations were either stable or increased. Furthermore, duodenal switch patients had lower hemoglobin and total cholesterol concentrations and a lower BMI (mean reduction: 41% compared with 30%) than did gastric bypass patients 1 y after surgery. Additional dietary supplement use was more frequent among duodenal switch patients (55%) than among gastric bypass patients (26%). CONCLUSIONS Compared with gastric bypass, duodenal switch may be associated with a greater risk of vitamin A and D deficiencies in the first year after surgery and of thiamine deficiency in the initial months after surgery. Patients who undergo these 2 surgical interventions may require different monitoring and supplementation regimens in the first year after surgery. This trial was registered at ClinicalTrials.gov as NCT00327912.

A comparative study of the short-term outcome following open and laparoscopic liver resection of colorectal metastases

Background: Laparoscopic resection of liver tumors is feasible, but few studies have compared short-term outcome of the laparoscopic approach to that of a conventional technique. Methods: Eighteen tumor resections performed during 14 procedures (14 patients) by conventional surgery were compared to 21 similar resections performed laparoscopically during 15 procedures (13 patients). All patients had colorectal liver metastases. Results: No perioperative mortality occurred. Surgical time, peroperative bleeding and blood transfusion requirement were similar in the two groups. The resection margin was involved by tumor tissue in one specimen laparoscopically resected and in two specimens conventionally resected (p = 0.58). Patients operated laparoscopically remained in hospital for median 4 days, while patients operated conventionally stayed median 8.5 days (p <0.001). Patients operated laparoscopically required less opioid medication than patients having conventional surgery (median 1 vs 5 days; p = 0.001). Conclusions: Short-term outcome of laparoscopic liver resection compares to that of conventional surgery, with the additional benefits derived from minimal invasive therapy.

Weight loss, cardiovascular risk factors, and quality of life after gastric bypass and duodenal switch: a randomized trial.

BACKGROUND Gastric bypass and duodenal switch are currently performed bariatric surgical procedures. Uncontrolled studies suggest that duodenal switch induces greater weight loss than gastric bypass. OBJECTIVE To determine whether duodenal switch leads to greater weight loss and more favorable improvements in cardiovascular risk factors and quality of life than gastric bypass. DESIGN Randomized, parallel-group trial. (ClinicalTrials.gov registration number: NCT00327912) SETTING 2 academic medical centers (1 in Norway and 1 in Sweden). PATIENTS 60 participants with a body mass index (BMI) between 50 and 60 kg/m(2). INTERVENTION Gastric bypass (n = 31) or duodenal switch (n = 29). MEASUREMENTS The primary outcome was the change in BMI after 2 years. Secondary outcomes included anthropometric measures; concentrations of blood lipids, glucose, insulin, C-reactive protein, and vitamins; and health-related quality of life and adverse events. RESULTS Fifty-eight of 60 participants (97%) completed the study. The mean reductions in BMI were 17.3 kg/m(2) (95% CI, 15.7 to 19.0 kg/m(2)) after gastric bypass and 24.8 kg/m(2) (CI, 23.0 to 26.5 kg/m(2)) after duodenal switch (mean between-group difference, 7.44 kg/m(2) [CI, 5.24 to 9.64 kg/m(2)]; P < 0.001). Total cholesterol concentration decreased by 0.24 mmol/L (CI, -0.03 to 0.50 mmol/L) (9.27 mg/dL [CI, -1.16 to 19.3 mg/dL]) after gastric bypass and 1.07 mmol/L (CI, 0.79 to 1.35 mmol/L) (41.3 mg/dL [CI, 30.5 to 52.1 mg/dL]) after duodenal switch (mean between-group difference, 0.83 mmol/L [CI, 0.48 to 1.18 mmol/L]; 32.0 mg/dL [CI, 18.5 to 45.6 mg/dL]; P ≤ 0.001). Reductions in low-density lipoprotein cholesterol concentration, anthropometric measures, fat mass, and fat-free mass were also greater after duodenal switch (P ≤ 0.010 for each between-group comparison). Both groups had reductions in blood pressure and mean concentrations of glucose, insulin, and C-reactive protein, with no between-group differences. The duodenal switch group, but not the gastric bypass group, had reductions in concentrations of vitamin A and 25-hydroxyvitamin D. Most Short Form-36 Health Survey dimensional scores improved in both groups, with greater improvement in 1 of 8 domains (bodily pain) after gastric bypass. From surgery until 2 years, 10 participants (32%) had adverse events after gastric bypass and 18 (62%) after duodenal switch (P = 0.021). Adverse events related to malnutrition occurred only after duodenal switch. LIMITATION Clinical experience was greater with gastric bypass than with duodenal switch at the study centers. CONCLUSION Duodenal switch surgery was associated with greater weight loss, greater reductions of total and low-density lipoprotein cholesterol concentrations, and more adverse events. Improvements in other cardiovascular risk factors and quality of life were similar after both procedures. PRIMARY FUNDING SOURCE South-Eastern Norway Regional Health Authority.

Laparoscopic resection of the pancreas: a feasibility study of the short-term outcome

Background: Laparoscopic resection is not an established treatment for tumors of the pancreas. We report our preliminary experience with this innovative approach to pancreatic disease. Methods: Thirty two patients with pancreatic disease were included in the study on an intention-to-treat basis. The preoperative indications for surgery were as follows: neuroendocrine tumors (n=13), unspecified tumors (n=11), cysts (n=2), idiopathic thrombocytopenic purpura with ectopic spleen (n=2), annular pancreas (n=1), trauma (n=1), aneurysm of the splenic artery (n=1), and adenocarcinoma (n=1). Results: Enucleations (n=7) and distal pancreatectomy with (n=12) and without splenectomy (n=5) were performed. Three patients underwent laparoscopic exploration only. Four procedures (13%) were converted to an open technique. One resection was converted to a hand-assisted procedure. The mortality rate for patients undergoing laparoscopic resection was 8.3% (two of 24). Complications occurred after resection in nine of 24 procedures (38%). The median hospital stay was 5.5 days (range, 2–22). Postoperatively, opioid medication was given for a median of 2 days (range, 0–13). Conclusion: Resection of the pancreas can be performed safely via the laparoscopic approach with all the potential benefits to the patients of minimally invasive surgery.

Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity

Laparoscopic Roux‐en‐

Hepatic resection for colorectal metastases: Can preoperative scoring predict patient outcome?

\font\ss=cmss10 scaled 1000 \hbox{Y}

Microsatellite instability has a positive prognostic impact on stage II colorectal cancer after complete resection: results from a large, consecutive Norwegian series

gastric bypass (LRYGB) and laparoscopic biliopancreatic diversion with duodenal switch (LDS) are surgical options for superobesity. A randomized trial was conducted to evaluate perioperative (30‐day) safety and 1‐year results.

Laparoscopic liver resection for malignant and benign lesions: ten-year Norwegian single-center experience.

A retrospective study was performed to define patient selection, safety, and efficacy of hepatic resection for colorectal metastases. The recently proposed preoperative clinical risk score (CRS) for selection of patients for surgery was also assessed. In all, 146 consecutive hepatic resections in 137 patients operated in the period between 1977 and 1999 were studied. Of these patients, 113 were classified into five CRS groups. Perioperative mortality was 1.4% (2 patients; no death in 120 patients operated after 1985) and morbidity was 38%. Five-year actuarial survival (perioperative mortality included) was 29% (median 37 months), and actual 5-year survival was 25% (17/69 patients). Patients operated after 1995 lived longer than those operated before 1995. Multiple regression analyses identified preoperative carcinoembryonic antigen CEA<100 µg/L, nodal status at resection of primary tumor, and RO vs. R1/R2 resection as prognostic parameters. CRS grouping had prognostic importance. The relative risk (hazard rate) of tumor recurrence in patients with CRS 3–4 was 2.1, compared to that of patients with CRS 0–2. Five-year actuarial survival in the two groups was 12% and 40%, respectively. Fourteen of 15 long-term survivors (τ;5 years) classified by the CRS system had CRS of 2 or less. Resection for colorectal liver metastases is safe, and long-term survival rates are acceptable. CRS predicts patient outcome, but the clinical role in patient selection will have to be defined in prospective studies.ResumeUne étude rétrospective a été réalisée pour définir la sélection des patients, la sûreté et l’efficacité de la résection hépatique pour métastases d’origine colorectale. Le score préopératoire «Clinical Risk Score» (CRS), proposé récemment pour la sélection des patients candidats à la chirurgie, a été évalué chez 146 patients consécutifs ayant eu une résection hépatique entre 1977 et 1999; 113 de ces patients ont été classés en cinq groupes selon le CRS. La mortalité périopératoire a été de 1.4% (2 patients; aucune mortalité parmi 120 patients opérés après 1985) et la morbidité, de 38%. La survie actuarielle à 5 ans (mortalité périopératoire incluse) a été de 29% (médiane de 37 mois) et la survie actuelle à 5 ans a été de 25% (17/69 patients). Les patients opérés après 1995 ont survécu plus longtemps que ceux opérés avant 1995. L’analyse par régression multiple a identifié comme facteurs pronostiques, le taux d’ACE inférieur à 100 ng/1, l’état ganglionnaire au moment de la résection tumorale primitive et une résection R0 vs. une résection R1/R2. Le risque relatif de récidive chez les patients CRS 3–4 a été de 2.1 comparé à celui des patients CRS 0–2. La survie actuarielle à 5 ans a été, respectivement, de 12% et de 40%. Quatorze des 15 survivants à long terme (τ; 5 ans), classés par le système CRS, avaient un score de 2 ou moins. La résection des métastases colorectales est sure et la survie à long terme, acceptable. Le score CRS prédit l’évolution mais son rôle clinique dans la sélection des patients reste à être défini par des études prospectives.ResumenPara seleccionar de manera eficaz y segura a los pacientes subsidiarios de resección hepática por padecer metástasis en hígado de un cáncer colorrectal, se realiza un estudio retrospectivo, en el que se valoró la clasificación reciente de Riesgo Clínico (CRS). Se estudiaron 146 resecciones hepáticas en 137 pacientes intervenidos entre 1977 y 1999. 113 de estos pacientes se clasificaron en alguno de los cinco grupos de la CRS. La mortalidad perioperatoria fue del 1.4% (2 pacientes; no se registró mortalidad alguna en los 120 pacientes intervenidos después del año 1985) y la morbilidad del 38%. La supervivencia actuarial a los 5 años (incluyendo la mortalidad perioperatoria) fue del 29% (media 37 meses) y la supervivencia actual a los 5 años fue del 25% (17/69 pacientes). Los enfermos intervenidos después de 1995 vivieron más tiempo que los operados con anterioridad. Los análisis de regresión múltiple señalaron como parámetros pronósticos: CEA preoperatorio menor de 100 ng/1, grado de afectación ganglionar en la resección del tumor primario y resección R0 vs R1/R2. La clasificación CRS tiene importancia pronóstica. El riesgo relativo de recidiva tumoral en pacientes de los grupos CRS 3–4 fue 2.1 en relación con la de los grupos CRS 0–2. La supervivencia actuarial a los 5 años fue respectivamente del 12% y 40%. 14 de los 15 supervivientes a largo plazo (τ;5 años) clasificados con el sistema CRS pertenecían a los grupos CRS 2 ó menores. El sistema CRS permite pronosticar los resultados, pero el papel del estudio clínico en la selección de los pacientes ha de definirse mejor en próximos estudios prospectivos.

Five-Year Outcomes After Laparoscopic Gastric Bypass and Laparoscopic Duodenal Switch in Patients With Body Mass Index of 50 to 60: A Randomized Clinical Trial

Background Microsatellite instability (MSI) was suggested as a marker for good prognosis in colorectal cancer in 1993 and a systematic review from 2005 and a meta-analysis from 2010 support the initial observation. We here assess the prognostic impact and prevalence of MSI in different stages in a consecutive, population-based series from a single hospital in Oslo, Norway. Patients and methods Of 1274 patients, 952 underwent major resection of which 805 were included in analyses of MSI prevalence and 613 with complete resection in analyses of outcome. Formalin-fixed tumor tissue was used for PCR-based MSI analyses. Results The overall prevalence of MSI was 14%, highest in females (19%) and in proximal colon cancer (29%). Five-year relapse-free survival (5-year RFS) was 67% and 55% (P = 0.030) in patients with MSI and MSS tumors, respectively, with the hazard ratio (HR) equal to 1.60 (P = 0.045) in multivariate analysis. The improved outcome was confined to stage II patients who had 5-year RFS of 74% and 56% respectively (P = 0.010), HR = 2.02 (P = 0.040). Examination of 12 or more lymph nodes was significantly associated with proximal tumor location (P < 0.001). Conclusions MSI has an independent positive prognostic impact on stage II colorectal cancer patients after complete resection.

Percutaneous endoscopic gastrostomy in children : A safe technique with major symptom relief and high parental satisfaction

BACKGROUND The introduction of laparoscopic liver resection has been challenging because new and safe surgical techniques have had to be developed, and skepticism remains about the use of laparoscopy for malignant neoplasms. We present herein a large-volume single-center experience with laparoscopic liver resection. DESIGN Retrospective study. SETTING Rikshospitalet University Hospital. PATIENTS One hundred thirty-nine patients who underwent 177 laparoscopic liver resections in 149 procedures from August 18, 1998, through October 14, 2008. One hundred thirteen patients had malignant lesions, of whom 96 had colorectal metastases. INTERVENTION Laparoscopic liver resection for malignant and benign lesions. MAIN OUTCOME MEASURES Perioperative and oncologic outcomes and survival. RESULTS Five procedures (3.4%) were converted to laparotomy and 1 (0.7%) to laparoscopic radiofrequency ablation. The remaining 143 procedures were completed laparoscopically, during which 177 liver resections were undertaken, including 131 nonanatomic and 46 anatomic resections. The median operative time and blood loss were 164 (50-488) minutes and 350 (<50-4000) mL, respectively. There were 10 intraoperative (6.7%) and 18 postoperative (12.6%) complications. One patient (0.7%) died. The median postoperative stay and opioid requirement were 3 (1-42) and 1 (0-11) days, respectively. Tumor-free resection margins determined by histopathologic evaluation were achieved in 140 of 149 malignant specimens (94.0%). The 5-year actuarial survival for patients undergoing procedures for colorectal metastases was 46%. CONCLUSIONS In experienced hands, laparoscopic liver resection is a favorable alternative to open resection. Perioperative morbidity and mortality and long-term survival after laparoscopic resection of colorectal metastases appear to be comparable to those after open resections.