Clinical Challenges in Upper Gastrointestinal Malignancies after Bariatric Surgery.

BACKGROUND/AIMS: The incidence of morbid obesity has exponentially increased over the last decades. Bariatric surgery (BS) has been proven effective in inducing weight loss and resolving comorbidities associated with morbid obesity. However, BS can also lead to major diagnostic and treatment challenges in patients who develop upper gastrointestinal malignancies. It is important to create awareness of this rising problem. METHODS: Relevant literature was searched in PubMed. RESULTS: (Formerly) obese patients are more prone to develop upper gastrointestinal malignancies, mainly adenocarcinoma of the distal esophagus, since obesity induces a chronic pro-inflammatory state due to endocrinological changes. When an upper gastrointestinal malignancy develops after BS, diagnosis is often delayed and challenging due to a different presentation of complaints and the altered anatomy following the earlier surgery. Also, a potentially curative resection is often more complex and reconstruction of the gastrointestinal continuity can be seriously hampered. CONCLUSION: Due to the growing incidence of obesity and the increasing number of bariatric surgical procedures that are performed each year, it is expected that over the years to come, more post-BS patients will be diagnosed with upper gastrointestinal malignancies, providing great diagnostic and treatment challenges. Clinicians should be aware of this rising problem.

Perforation of the gastric remnant in a patient post-Roux-en-Y gastric bypass.

With the dramatic increase in obesity surgery and the subsequent increase in ageing post-gastric bypass patients, early recognition of possible and serious complications is of the utmost importance. We present a case of a 33-year-old woman who presented to the emergency room, with progressive epigastric pain. The patient had undergone laparoscopic Roux-en-Y gastric bypass surgery 14 months earlier. Diagnostic laparoscopy was performed and showed a prepyloric perforation of the gastric remnant. The defect was closed and omentoplasty was performed. The patient was put on lifelong proton pump inhibitors.

Challenges of improving the evidence base in smaller surgical specialties, as highlighted by a systematic review of gastroschisis management.

OBJECTIVE: To identify methods of improving the evidence base in smaller surgical specialties, using a systematic review of gastroschisis management as an example. BACKGROUND: Operative primary fascial closure (OPFC), and silo placement with staged reduction and delayed closure (SR) are the most commonly used methods of gastroschisis closure. Relative merits of each are unclear. METHODS: A systematic review and meta-analysis was performed comparing outcomes following OPFC and SR in infants with simple gastroschisis. Primary outcomes of interest were mortality, length of hospitalization and time to full enteral feeding. RESULTS: 751 unique articles were identified. Eight met the inclusion criteria. None were randomized controlled trials. 488 infants underwent OPFC and 316 underwent SR. Multiple studies were excluded because they included heterogeneous populations and mixed intervention groups. Length of stay was significantly longer in the SR group (mean difference 8.97 days, 95% CI 2.14-15.80 days), as was number of post-operative days to complete enteral feeding (mean difference 7.19 days, 95%CI 2.01-12.36 days). Mortality was not statistically significantly different, although the odds of death were raised in the SR group (OR 1.96, 95%CI 0.71-5.35). CONCLUSIONS: Despite showing some benefit of OPFC over SR, our results are tempered by the low quality of the available studies, which were small and variably reported. Coordinating research through a National Paediatric Surgical Trials Unit could alleviate many of these problems. A similar national approach could be used in other smaller surgical specialties.

Do we overestimate the endothelial cell "loss" after descemet membrane endothelial keratoplasty?

PURPOSE: To evaluate how corneal deturgescence after Descemet membrane endothelial keratoplasty (DMEK) influences the posterior corneal surface area and the endothelial cell density (ECD) measurements. MATERIALS AND METHODS: A mathematical model was formulated to estimate the increase in posterior corneal surface area associated with postoperative corneal deturgescence and its effect on ECD measurements. Important input parameter for the model was the change in pachymetry from 1 h to 6 months after surgery. To this end, the clinical records of 25 patients (25 eyes) who underwent DMEK were reviewed retrospectively and the central corneal thickness (CCT) measurements taken after 1 h, 1 month, 3 months and 6 months were noted. ECD measurements before surgery and at 1, 3 and 6 months after surgery were also recorded and decrease in pachymetry and ECD loss were calculated. RESULTS: The average decrease in CCT due to corneal deturgescence was 267 µm (±39 µm), which corresponds to an 8.6% increase in total posterior corneal surface area, as calculated using our mathematical model. The stretching of the endothelial cell layer associated with this increase of posterior corneal surface area may result in an apparent endothelial cell "loss". This might account for approximately 25% of the observed average ECD decrease of 34% (±17%). CONCLUSIONS: The observed decrease in ECD within the first 6 months after DMEK may overestimate the actual loss of endothelial cells by about 8% due to increased posterior corneal surface area associated with postoperative corneal deturgescence.

Near complete visual recovery and refractive stability in modern corneal transplantation: Descemet membrane endothelial keratoplasty (DMEK).

OBJECTIVE: To report the 6 months results of a large prospective study on Descemet membrane endothelial keratoplasty (DMEK) for management of corneal endothelial disorders. METHODS: DMEK was performed in 300 consecutive eyes with Fuchs endothelial dystrophy, bullous keratopathy or previous corneal transplant failure. Best spectacle corrected visual acuity (BSCVA), refractive outcome and endothelial cell density (ECD) were evaluated before and at 1, 3, and 6 months after surgery. Intra- and postoperative complications were documented. RESULTS: At 6 months, 98% of eyes reached a BCVA of ≥20/40 (≥0.5), 79% ≥20/25 (≥0.8), 46% ≥20/20 (≥1.0), and 14% ≥20/18 (≥1.2) (n=221). The pre- to 6 months postoperative spherical equivalent (SE) showed a +0.33D (±1.08D) hyperopic shift (P=0.0000). Refractive stability was shown at 3 months after DMEK, i.e. no significant change in SE (P=0.0822) or refractive cylinder (P=0.6182) at 3 versus 6 months follow-up. Donor ECD showed a decrease from 2561 (±198)cells/mm(2) before, to 1674 (±518)cells/mm(2) at 6 months after surgery (n=251) (P=0.0000). The main complication was (partial) graft detachment occurring in 31 eyes (10%). Secondary ocular hypertension was seen in 13 eyes (6%): 6 induced by air-bubble dislocation posterior to the iris and 4 induced by steroids. Secondary cataract requiring phaco-emulsification developed in 3 out of 63 (5%) phakic eyes. CONCLUSIONS: DMEK may provide a refractively neutral near complete, rapid visual rehabilitation with ECDs similar to earlier endothelial keratoplasty techniques. This combined with a relatively low complication rate, would indicate that DMEK is a safe and effective treatment for corneal endothelial disorders.

Outcomes of Descemet membrane endothelial keratoplasty in phakic eyes.

PURPOSE: To determine the clinical outcomes of isolated Descemet membrane transplantation (ie, Descemet membrane endothelial keratoplasty [DMEK]) in phakic eyes. SETTING: Tertiary referral center. DESIGN: Cohort study. METHODS: Phakic eyes from a larger group of consecutive eyes that had DMEK for Fuchs endothelial dystrophy were examined. The examination included corrected distance visual acuity (CDVA), subjective and objective refractions, endothelial cell density (ECD), and intraoperative and postoperative complications at 1, 3, and 6 months. RESULTS: The study enrolled 52 phakic eyes from a group of 260 DMEK eyes. Of the phakic eyes, 69% reached a CDVA equal to or better than 20/40 (≥0.5) within 1 week and 85% reached equal to or better than 20/25 (≥0.8) at 6 months. Compared with an age-matched control group of pseudophakic eyes, phakic eyes had a similar visual rehabilitation rate, final visual outcome, mean ECD at 6 months (1660 cells/mm(2) ± 470 [SD]), minor hyperopic shift (+0.74 diopter), and graft detachment rate (4%). Visual acuity equal to or better than 20/13 (≥1.5) was limited to phakic eyes, suggesting better optical quality with the crystalline lens in situ. Temporary mechanical angle-closure glaucoma due to air-bubble dislocation behind the iris was the main complication (11.5%). Two eyes (4%) required phacoemulsification after DMEK. CONCLUSIONS: In phakic eyes, DMEK may give excellent visual outcomes without an increased risk for complications. Visual acuities equal to or better than 20/13 (≥1.5) may indicate that the almost anatomic repair after DMEK is associated with near perfect optical quality of the transplanted cornea. FINANCIAL DISCLOSURE: Dr. Melles is a consultant to D.O.R.C. International/Dutch Ophthalmic USA. No author has a financial or proprietary interest in any material or method mentioned.