Critical assessment of the current guidelines for the management and treatment of morbidly obese patients.

An interdisciplinary panel of specialists met in Mallorca in the first European Symposium on Morbid Obesity entitled; "Morbid Obesity, an Interdisciplinary Approach". During the two and half days of the meeting, the participants discussed several aspects related to pathogenesis, evaluation, and treatment of morbid obesity. The expert panel included basic research scientists, dietitians and nutritionists, exercise physiologists, endocrinologists, psychiatrists, cardiologists, pneumonologists, anesthesiologists, and bariatric surgeons with expertise in the different weight loss surgeries. The symposium was sponsored by the Balearic Islands Health Department; however, this statement is an independent report of the panel and is not a policy statement of any of the sponsors or endorsers of the Symposium. The prevalence of morbid obesity, the most severe state of the disease, has become epidemic. The current recommendations for the therapy of the morbidly obese comes as a result of a National Institutes of Health (NIH) Consensus Conference held in 1991 and subsequently reviewed in 2004 by the American Society for Bariatric Surgery. This document reviews the work-up evaluation of the morbidly obese patient, the current status of the indications for bariatric surgery and which type of procedure should be recommended; it also brings up for discussion some important real-life clinical practice issues, which should be taken into consideration when evaluating and treating morbidly obese patients. Finally, it also goes through current scientific evidence supporting the potential effectiveness of medical therapy as treatment of patients with morbid obesity.

Laparoscopic biliopancreatic diversion with duodenal switch: technique and initial experience.

BACKGROUND: The duodenal Switch (DS) is a variant of the biliopancreatic diversion (BPD) for the surgical treatment of morbid obesity. MATERIALS AND METHODS: The laparoscopic DS (LapDS) operation is described, and the early surgical outcomes of 16 patients are reported. RESULTS: Postoperative stay was 5 to 8 days. Local wound infection at a trocar site was the most common local complication. CONCLUSION: LapDS is an advanced, complex and feasible technique in bariatric surgery.

Duodenal switch: an effective therapy for morbid obesity--intermediate results.

BACKGROUND: The duodenal switch (DS) is a variant of the biliopancreatic diversion (BPD), with a vertical subtotal gastrectomy and pylorus preservation. METHODS: DS was used to treat morbid obesity in 125 patients, with mean BMI 50, with 65% of the patients super obese (SO). Patients have been followed for an intermediate period. RESULTS: The percentage of excess weight loss (%EWL) was > 70% at 1 year, and reached 81.4% at 5 years when 97% of the patients had a %EWL > 50%. Comorbidities were cured or improved in all patients. CONCLUSION: DS was very effective for the treatment of the morbid obesity in the SO patients.

Immunohistochemical study of pepsinogen C expression in cutaneous malignant melanoma: association with clinicopathological parameters.

BACKGROUND: The aim of this study was to evaluate the pepsinogen C expression in malignant cutaneous melanomas and analyze its possible relationship to clinical and pathological parameters. Pepsinogen C is an aspartyl proteinase primarily involved in the digestion of proteins in the stomach and represents one of the main androgen-inducible proteins in breast cancer cells. METHOD: Tumoral pepsinogen C expression was retrospectively analyzed in 35 paraffin-embedded tissues from patients with primary malignant cutaneous melanoma and in 10 samples from 10 benign lesions (4 dermal melanocytic nevi, 4 compound melanocytic nevi and 2 dysplastic melanocytic nevi), using immunohistochemical methods. RESULTS: The benign lesions were consistently negative for pepsinogen C, whereas 20 of the 35 malignant melanomas (57%) showed positive immunostaining for pepsinogen C. The percentage of pepsinogen C-positive tumors was significantly higher in men than in women (p=0.01) and in epithelioid melanomas than in fusocellular or mixed type melanomas (p=0.003). In addition, the percentage of pepsinogen-C positive tumors was positively and significantly correlated with lesion thickness (p=0.003), Clark's level of invasion (p=0.028) and tumor stage (p<0.001). CONCLUSION: Pepsinogen C could be a new prognosticator of unfavorable outcome in cutaneous malignant melanoma.

Comparative study of two androgen-induced markers (apolipoprotein D and pepsinogen C) in female and male breast carcinoma.

BACKGROUND: Male breast cancer (MBC) is a rare tumor in comparison to the same disease in the female population (FBC). Classical prognostic factors (tumor size, node status, estrogen receptor positivity, histological grade) have a similar prognostic value in both tumors, but MBC seems to have a worse outcome. Several markers under estrogen control have been shown with a similar incidence in breast tumors of both sexes, while androgen-induced markers have been detected in a higher percentage of breast tumors in males. AIMS AND METHODS: Our purpose was to compare in 68 MBC and in 68 FBC the expression of Pepsinogen C (Pep C) and Apolipoprotein D (Apo D), two proteins under androgen control, by immunohistochemical methods. RESULTS: Pep C was expressed by 52 of 68 (76.4%) MBC patients, whereas 34 of 68 (50%) FBC showed positive staining. Apo D was expressed by 57 of 68 (83.8%) MBC patients, while 40 of 68 (41.2%) FBC stained positively. Differences between percentages of positive expression were significant (p<0.005 for Pep C; p<0.0001 for Apo D). Moreover, differences between expression levels of Pep C and Apo D in both populations of patients were significant. The mean value of Pep C was significantly higher in male breast tumors (HSCORE = 141.3) than in the females (HSCORE = 80.3) (p<0.0001). Similarly, Apo D mean value was significantly higher in MBC (HSCORE = 161.5) than in FBC (HSCORE = 102.3) (p=0.006). CONCLUSION: These differences can open the field of a more selective hormonal therapy that should not be based on estrogen receptor status only, but also on androgen receptor status.

Expression and clinical significance of apolipoprotein D in male breast cancer and gynaecomastia.

BACKGROUND: Apolipoprotein D (Apo D) is a protein component of the human plasma lipid transport system which is present in benign and malignant human breast tissues. This study analysed the expression of Apo D in men with gynaecomastia or breast cancer, and evaluated its use as a prognostic marker in breast cancer. METHODS: Immunohistochemical expression of Apo D was examined in specimens from 15 men with gynaecomastia, two with in situ breast carcinoma and 68 with invasive male breast cancer. Median follow-up in patients with breast cancer was 44 months. RESULTS: All gynaecomastia specimens, both in situ carcinomas and 57 invasive carcinomas (84 per cent) stained positively for Apo D. Apo D values were significantly correlated with axillary node involvement and histological grade of the tumours. In men with breast cancer univariate analysis showed a statistical association between node status and Apo D content with relapse-free survival (P < 0.001) and overall survival (P < 0.05). Cox multivariate analysis showed that Apo D was a significant indicator of relapse-free survival (P = 0. 0089), but node status was the strongest factor able to predict both relapse-free (P = 0.0336) and overall (P = 0.0346) survival. CONCLUSION: Apo D was expressed in gynaecomastia and a high percentage of male breast carcinomas. There was a positive association of Apo D content in male breast tumours with favourable outcome. Apo D expression was a significant independent indicator of relapse-free survival in male breast cancer.

Expression of pepsinogen C in gynecomastias and male breast carcinomas.

Pepsinogen C is a proteolytic enzyme involved in the digestion of proteins in the stomach; it is also synthesized by a significant percentage of female breast carcinomas. In addition, it has been demonstrated that pepsinogen C is one of the few proteins induced by androgens in breast carcinoma cells. Here we evaluate the expression of pepsinogen C by immunoperoxidase staining in normal breast tissue from 3 male patients, 15 gynecomastia tissues, 2 male in situ breast carcinomas, and 68 male invasive breast carcinomas. Pepsinogen C immunostaining values were quantified in male breast tumors using the HSCORE system, which considers both the intensity and the percentage of cells staining at each intensity. The results indicated positive immunohistochemical staining for pepsinogen C in all gynecomastia tissues, the two in situ ductal carcinomas, and 52 of 68 invasive breast carcinomas (76.4%). The three normal breast tissues analyzed showed negative staining for pepsinogen C, whereas invasive tumors showed clear differences among them with regard to the intensity and percentage of staining cells. In addition, pepsinogen C scores were significantly higher in well-differentiated (grade I, 188.7) and moderately differentiated (grade II, 145.8) tumors than in poorly differentiated (grade III, 98.5) tumors (p = 0. 032). Similarly, significant differences in pepsinogen C content were found between estrogen receptor (ER)-positive tumors and ER-negative tumors (158.5 vs. 44.3, respectively; p = 0.009). Patients with pepsinogen C-positive tumors reached longer relapse-free and overall survival periods than did those with tumors with negative staining, but no statistical differences were observed between survival curves calculated for these two groups of patients. This results demonstrate expression of pepsinogen C by gynecomastias and by a high percentage of male breast carcinomas and may indicate an important role of pepsinogen C in the pathophysiology of male breast diseases.

Internal hernias and gastric perforation after a laparoscopic gastric bypass.

A 27-year-old woman underwent laparoscopic Rouxen-Y gastric bypass. A retrocolic-retrogastric herniation of most of the small bowel and later a gastric perforation due to internal hernia at the mesenteric defect of the jejuno-jejunostomy occurred. These unusual, but not rare, complications are directly related to the neoanatomy that follows gastric bypass and can lead to rapidly progressing and life-threatening situations. Proper evaluation of clinical signs and symptoms, early abdominal CT scan, and urgent operative intervention are mandatory to achieve a successful outcome.

Vertical banded gastroplasty at more than 5 years.

BACKGROUND: Optimal evaluation of the results of surgery for morbid obesity requires a long-term follow-up for at least 5 years. METHODS: One hundred patients were operated by vertical banded gastroplasty (VBG) and revised with a follow-up of no less than 5 years. Sixty patients were morbidly obese with a body mass index (BMI) of between 40 and 50 kg/m2, and 40 were super-obese with a BMI of >50 kg/m2. Follow-up included 93 patients (93%). RESULTS: Initial surgical mortality was nil. Twenty-five patients required surgery for complications related to the technique (25%) and one patient died due to pulmonary embolism after a re-stapling operation. The percentage excess weight loss was 54.3%, and the BMI was 33 kg/m2 for the 84 patients followed to 5 years post VBG. Only 40 out of 92 patients (43.5%), obtained the weight loss benefit due to the operation. None of them is able to eat a regular diet, and the quality of food intake has been severely affected in some of them. CONCLUSIONS: VBG is, in our experience, a safe and technically simple operation, but the long-term results are questionable. The reoperation rate was high, and weight loss and quality of life are superior with other operations.

Preliminary results of the duodenal switch.

BACKGROUND: The duodenal switch (DS), as a modification of the bilio-pancreatic diversion (BPD), is a 'complex' hybrid operation. METHODS: Sixty patients were operated on during the last 3 years. RESULTS: Two patients died early (3.3%); two late deaths occurred at 4 and 7 months, one due to liver failure and the other due to malnutrition and refeeding syndrome (3.57%); three patients required conversions (5.3%). The two early deaths and all the patients who required conversions had a previous vertical banded gastroplasty. Eleven patients had minor liver abnormalities corrected with medications, and one patient had severe diarrhea for more than a year. Eleven female patients have iron deficiency anemia that requires parenteral supplementation. Mean percent excess weight loss was 86% at 2.5 years. CONCLUSIONS: The DS has been, in our experience, an unsafe operation with unacceptably high operative and postoperative mortality. The conversion rate is acceptable. Weight loss, quality of food intake and life have been excellent. Inadequate follow-up can be dangerous if patients fail to report for regular visits.

[A new method of studying gastric emptying in gastrectomized patients]. / Nuevo método de estudio del vaciado gástrico en pacientes gastrectomizados.

OBJECTIVE: We present a new method of assessment of gastric emptying in gastrectomized patients. PATIENTS AND METHODS: The gastric emptying of non digestible solids were studied in two groups of gastrectomized patients, the Billroth II (n = 25) and the Roux-en-Y (n = 36) to relate the gastric emptying with the postgastrectomy symptoms. RESULTS: The food retained in the gastric stump is related with significance with the presence (p = 0.01) and the absence (p = 0.02) of markers. The patients operated on with the Billroth II technique present a higher frequency of markers in the gastric stump (40% over 19.4% with the Roux-en-Y). The markers in the gastric stump are more common with the symptoms of pyrosis, nausea, bilious vomit, diarrhea and the postoperative gastritis of alkaline reflux. CONCLUSIONS: The method of gastric emptying of non digestible solids is a valid and reliable study of the gastric emptying and should be carried out in all candidates for endoscopy because it is harmless and easy to perform and evaluate.

[Gastric duplication in an adult]. / Duplicación gástrica en el adulto.

A gastric cystic duplication was found in a 83 year old patient; the cyst was located on the posterior wall of the stomach and required a total gastrectomy. Gastric duplications are usually discovered during the first year of life. They are located in the greater curvature. It's common the cystic form without communication with the gastric lumen. Due to its rarity, in most cases the diagnosis is made at laparotomy.

[Enteritis caused by small intestine irradiation]. / Enteritis por radiación de intestino delgado.

Two cases of small bowel postradiation enteritis after abdominoperineal resection are presented. The interval between radiation of 60 Gy to the pelvis and perineal area and the occlusive symptoms were 3 and 6 years. One patient required a massive small bowel resection, and the second an ileo-transverse colon bypass. The first case had a partial dehiscence of the anastomosis, and the second a colonic fistula 8 months after surgery that closed after total parenteral nutrition. Both patients had abdominal wall closure defects.

[Synchronous pancreatic metastasis of renal carcinoma]. / Metástasis pancreática síncrona de un carcinoma renal.

A case of a large synchronous metastasis on the pancreas from a clear cell renal carcinoma is presented. The patient presented with melena from duodenal ulcer and a palpable mass in the mesogastrium. A radical right nephrectomy and cephalic duodenopancreatectomy were performed. Six years later bone and retroperitoneal metastasis developed and she died one year later. Renal clear cell carcinoma give pancreatic metastasis in only 1-3% of cases. Only 1-2% of the pancreatic malignancies are secondary to renal carcinoma. Clinical and radiological findings are similar to those of primary pancreatic tumors, and hemorrhage is the principal symptom. When the metastasis is single, as in this case, duodeno-pancreatectomy is the treatment of choice.

[Aneurysm of the abdominal aorta]. / Aneurisma de aorta abdominal.

OBJECTIVE: Three clinical cases of Aneurysm in the abdominal Aorta are presented, in order to make a clinical review of aneurysms in the abdominal Aorta (AAA) and underline the importance of their early diagnosis in Primary Care, given the risk factors. DESIGN: A retrospective, descriptive analysis of three cases of AAA from 1991. SITE. The patients studied had attended the hospital emergency department in the Alcoy Health area. MAIN MEASUREMENTS AND RESULTS: Case 1: A patient, who attended because of three days of bilateral lumbar pain of a colic type spreading to the mesogastrium, which did not respond to treatment for nephritic colic. The patient died in a few hours, with the diagnosis of hypovolaemic shock caused by a burst AAA. Case 2: A patient with generalised continuous abdominal pain, which over 12 hours had been located in the lower right hemiabdomen, who was admitted with the provisional diagnosis of acute pyelonephritis. Case 3: A patient who, after an emergency surgical intervention where the diagnosis of AAA was confirmed, presented after a month a clinical picture consistent with a cerebral vascular accident and died afterwards because of renal failure. CONCLUSION: Given the present increase of patients diagnosed in hospital as suffering AAA in our Health Area, we urge that special attention be paid to the early diagnosis of this pathology. It is important to look actively for this pathology in patients with chronic pathologies of high prevalence and include it in Primary Care preventive programmes.