Laparoscopic Sleeve Gastrectomy as a First Step Procedure for Oncologic Purposes: An Indication Beyond the Updated Guidelines.

BACKGROUND: Obesity is a well-established risk factor for cancer. Laparoscopic sleeve gastrectomy (LSG) is established as a safe procedure providing accelerated weight loss and comorbidity improvement or remission. Additionally, it is approved as a bridging procedure for various non-oncologic surgeries, with very limited data for oncologic procedures. The aim of this study is to present a series of patients with severe obesity and concomitant cancer who underwent LSG prior to definitive oncological procedure. METHODS: A retrospective review (2008-2023) was conducted in three institutions, identifying 5 patients with cancer and severe obesity who underwent LSG as bridging procedure. Variables analyzed were initial weight, initial body mass index (BMI), type of malignancy, comorbidities, interval between LSG and oncological surgery, weight and BMI before the second intervention, percentage of excess weight loss (%EWL), and postoperative morbidity and mortality. RESULTS: Malignancies identified were 2 prostate cancers, 1 periampullary neuroendocrine tumor, 1 rectal cancer, and 1 renal clear cell carcinoma. Mean age of patients was 50.2 years, mean initial BMI 47.4 kg/ m 2 , and mean BMI before oncological surgery 37 kg/ m 2 . Mean time interval between LSG and oncological surgery was 8.3 months. Mean %EWL achieved was 45.2%. Two thromboembolic events were encountered after LSG, while none of the patients developed complications after definitive oncological treatment. The mean follow-up after oncological surgery was 61.6 months. CONCLUSION: LSG can be proposed as bridging procedure before oncological surgery in meticulously selected patients. Achieved weight loss can render subsequent oncological procedures easier and safer.

Phenotype Prevalence and Health-Related Quality of Life of Lebanese Women With Polycystic Ovary Syndrome.

OBJECTIVE: Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders. Our study aimed to assess, for the first time, the phenotype prevalence and the health-related quality of life of Lebanese women with PCOS. METHODS: This was a cross-sectional study conducted on 322 Lebanese women with PCOS, using a questionnaire containing sociodemographic data, comorbidities, disease-related clinical questions, and the validated PCOS questionnaire (PCOSQ). The quality of life mean scores and phenotypes were compared and correlated among the different sociodemographic data, comorbidities, and disease-related questions. RESULTS: Phenotype A (67%) was the most common phenotype. High waist circumference and higher Body Mass Index (BMI) were reported mostly in classic phenotypes in comparison with nonclassic (P < .05). The mean total score of all PCOSQ domains was 3.61 ± 1.60. The mean score for each domain (from the greatest to the least serious concern) was menstrual problems (3.31 ± 1.26), emotion (3.33 ± 1.22), weight (3.41 ± 2.12), body hair (3.86 ± 1.79), and infertility (4.15 ± 1.61). Age was negatively correlated only to weight domain score (r = -0.17, P = .002). BMI was associated only with emotion and weight domain scores (P = .017 and P < .001, respectively). A bigger impairment in nearly all subscales of the PCOSQ in patients presenting with abdominal obesity, glucose intolerance, and increased blood pressure was noted (P < .05). CONCLUSION: Most Lebanese women with PCOS present phenotype A and have a serious impairment in their health-related quality of life, particularly in the menstrual and emotional domains. This highlights the need for community and individual support.

Gastroesophageal Cancer After Gastric Bypass Surgeries: a Systematic Review and Meta-analysis.

Data comparing the occurrence of gastroesophageal cancer after gastric bypass procedures are lacking and are only available in the form of case reports. We perform in this study a systematic review and a meta-analysis of all the reported cases of gastroesophageal cancer following Roux-en-Y gastric bypass (RYGB) and loop gastric bypass-one anastomosis gastric bypass/mini gastric bypass (LGB-OAGB/MGB). We conducted a systematic review of all the reported cases in articles referenced in PubMed/Medline, Cochrane, and Scholar Google. Only cases of gastro-esophageal adenocarcinoma following RYGB or LGB-OAGB/MGB are included. Statistical analysis was done accordingly. Fifty cases were identified, along with 2 reported in this paper. Sixty-one percent (27/44) of the cancers after RYGB were in the gastric tube compared to 37.5% (3/8) after LGB-OAGB/MGB. This resulted in an odds ratio of 0.38 (p-value = 0.26), which failed to prove an increase in cancer occurrence in the gastric tube after LGB-MGB/OAGB compared to RYGB. The most common symptoms were dysphagia for cancers occurring in the gastric tube (15/30) and abdominal pain for those occurring in the excluded stomach (10/22). Twenty-nine/thirty of the cancers in the gastric tube were diagnosed by gastroscopy and 13/22 of the cancers in the excluded stomach were diagnosed by CT scan. Gastroesophageal cancers after gastric bypass procedures occur commonly in the excluded stomach where many are not identified by conventional means. Physician awareness and patient education as well as lifelong follow-up are essential for maintaining bypass surgeries on the beneficial side.

ST segment elevation caused by ostial right coronary artery obstruction in infective endocarditis: a case report.

BACKGROUND: Acute coronary syndrome (ACS) is a rare, but serious complication of infective endocarditis, and diagnosis can be challenging given clinical overlap with other syndromes. A rare cause of ACS in infective endocarditis is mechanical obstruction of the coronary artery. We present the case of a patient with infective endocarditis who developed ST segment myocardial infarction due to occlusion of the right coronary artery ostium by a vegetation. CASE PRESENTATION: A 53-year-old female with no prior history of coronary artery disease was transferred to our tertiary care facility for evaluation and treatment of suspected myopericarditis. After transfer she developed inferior ST segment elevations on ECG along with fever and positive blood cultures for methicillin susceptible Staphylococcus aureus (MSSA). A transesophageal echocardiogram revealed a vegetation on the aortic valve that intermittently prolapsed into the right coronary ostium. She decompensated from a hemorrhagic brain infarct and subsequently transferred to the intensive care unit. She underwent surgical aortic valve debridement without prior cardiac catheterization given the danger of septic coronary embolization. After a prolonged hospital course with multiple complications, she was able to discharge home, with no neurologic deficits on follow-up. CONCLUSIONS: ACS presents a diagnostic and therapeutic challenge in the setting of infective endocarditis. Careful attention to the history, physical exam and testing can help differentiate infective endocarditis from other conditions sharing similar symptoms. Traditional atherosclerotic ACS management may cause great harm when treating patients with infective endocarditis. The presence of a multidisciplinary endocarditis team is ideal to provide the best clinical outcomes for this population.

Fibrotic Aortic Valve Stenosis in Hypercholesterolemic/Hypertensive Mice.

OBJECTIVE: Hypercholesterolemia and hypertension are associated with aortic valve stenosis (AVS) in humans. We have examined aortic valve function, structure, and gene expression in hypercholesterolemic/hypertensive mice. APPROACH AND RESULTS: Control, hypertensive, hypercholesterolemic (Apoe(-/-)), and hypercholesterolemic/hypertensive mice were studied. Severe aortic stenosis (echocardiography) occurred only in hypercholesterolemic/hypertensive mice. There was minimal calcification of the aortic valve. Several structural changes were identified at the base of the valve. The intercusp raphe (or seam between leaflets) was longer in hypercholesterolemic/hypertensive mice than in other mice, and collagen fibers at the base of the leaflets were reoriented to form a mesh. In hypercholesterolemic/hypertensive mice, the cusps were asymmetrical, which may contribute to changes that produce AVS. RNA sequencing was used to identify molecular targets during the developmental phase of stenosis. Genes related to the structure of the valve were identified, which differentially expressed before fibrotic AVS developed. Both RNA and protein of a profibrotic molecule, plasminogen activator inhibitor 1, were increased greatly in hypercholesterolemic/hypertensive mice. CONCLUSIONS: Hypercholesterolemic/hypertensive mice are the first model of fibrotic AVS. Hypercholesterolemic/hypertensive mice develop severe AVS in the absence of significant calcification, a feature that resembles AVS in children and some adults. Structural changes at the base of the valve leaflets include lengthening of the raphe, remodeling of collagen, and asymmetry of the leaflets. Genes were identified that may contribute to the development of fibrotic AVS.

Spontaneous Aortic Regurgitation and Valvular Cardiomyopathy in Mice.

OBJECTIVE: We studied the mechanistic links between fibrocalcific changes in the aortic valve and aortic valve function in mice homozygous for a hypomorphic epidermal growth factor receptor mutation (Wave mice). We also studied myocardial responses to aortic valve dysfunction in Wave mice. APPROACH AND RESULTS: At 1.5 months of age, before development of valve fibrosis and calcification, aortic regurgitation, but not aortic stenosis, was common in Wave mice. Aortic valve fibrosis, profibrotic signaling, calcification, osteogenic markers, lipid deposition, and apoptosis increased dramatically by 6 and 12 months of age in Wave mice. Aortic regurgitation remained prevalent, however, and aortic stenosis was rare, at all ages. Proteoglycan content was abnormally increased in aortic valves of Wave mice at all ages. Treatment with pioglitazone prevented abnormal valve calcification, but did not protect valve function. There was significant left ventricular volume overload, hypertrophy, and fetal gene expression, at all ages in Wave mice with aortic regurgitation. Left ventricular systolic function was normal until 6 months of age in Wave mice, but became impaired by 12 months of age. Myocardial transverse tubules were normal in the presence of left ventricular hypertrophy at 1.5 and 3 months of age, but became disrupted by 12 months of age. CONCLUSIONS: We present the first comprehensive phenotypic and molecular characterization of spontaneous aortic regurgitation and volume-overload cardiomyopathy in an experimental model. In Wave mice, fibrocalcific changes are not linked to valve dysfunction and are epiphenomena arising from structurally incompetent myxomatous valves.

Aortic valve sclerosis in mice deficient in endothelial nitric oxide synthase.

Risk factors for fibrocalcific aortic valve disease (FCAVD) are associated with systemic decreases in bioavailability of endothelium-derived nitric oxide (EDNO). In patients with bicuspid aortic valve (BAV), vascular expression of endothelial nitric oxide synthase (eNOS) is decreased, and eNOS(-/-) mice have increased prevalence of BAV. The goal of this study was to test the hypotheses that EDNO attenuates profibrotic actions of valve interstitial cells (VICs) in vitro and that EDNO deficiency accelerates development of FCAVD in vivo. As a result of the study, coculture of VICs with aortic valve endothelial cells (vlvECs) significantly decreased VIC activation, a critical early phase of FCAVD. Inhibition of VIC activation by vlvECs was attenuated by N(G)-nitro-l-arginine methyl ester or indomethacin. Coculture with vlvECs attenuated VIC expression of matrix metalloproteinase-9, which depended on stiffness of the culture matrix. Coculture with vlvECs preferentially inhibited collagen-3, compared with collagen-1, gene expression. BAV occurred in 30% of eNOS(-/-) mice. At age 6 mo, collagen was increased in both bicuspid and trileaflet eNOS(-/-) aortic valves, compared with wild-type valves. At 18 mo, total collagen was similar in eNOS(-/-) and wild-type mice, but collagen-3 was preferentially increased in eNOS(-/-) mice. Calcification and apoptosis were significantly increased in BAV of eNOS(-/-) mice at ages 6 and 18 mo. Remarkably, these histological changes were not accompanied by physiologically significant valve stenosis or regurgitation. In conclusion, coculture with vlvECs inhibits specific profibrotic VIC processes. In vivo, eNOS deficiency produces fibrosis in both trileaflet and BAVs but produces calcification only in BAVs.

Preventing staple-line leak in sleeve gastrectomy: reinforcement with bovine pericardium vs. oversewing.

One of the most serious, potentially life-threatening complications of laparoscopic sleeve gastrectomy (LSG) is staple-line leakage. Oversewing the LSG staple line vs buttressing it with bovine pericardial strips (BPS) to reduce perioperative bleeding and postoperative gastric leak was evaluated. From 2006 through 2011, 160 patients underwent LSG with suturing as the only staple-line reinforcement (Group A). From March 2010 through August 2012, 84 LSG patients had BPS incorporated into their last two stapler firings (Group B). Staple lines were evaluated perioperatively for bleeding, and patients were monitored for indications of staple-line leaks (peritonitis, abnormal output from the drain). In preoperative Group A and B, there were 117 (73.1%) vs. 56 (66.7%) females; mean age, 35.2 years (18.0-68.0) vs. 33.8 years (15.0-64.0); mean body mass index (BMI, kilograms per square meter), 42.5 (27.0-76.0) vs. 42.0 (30.0-58.0). Three months after surgery, mean BMI for Group A was 37.3 (-5.9); Group B, 35.2 (-7.3); at 6 months, 32.7 (-10.8) and 31.5 (-11.3; p < 0.001). Although there was no significant difference in perioperative blood loss, oversewn staple lines in Group A often required electrocautery to stanch bleeding; this was not required for Group B. In Group A, 15 patients (9.4%) developed complications; in Group B, five (6.0%; p = 0.46). Gastric fistula, verified by barium swallow, occurred in eight Group A patients (5.0%); in Group B, one (1.2%; p = 0.17). Relative to oversewing, staple-line buttressing with bovine pericardium was readily accomplished, safe, and associated with a lower staple-line leak rate.

Seizure-induced acute urate nephropathy: case report and review.

Urate nephropathy is observed primarily in patients treated for malignancy, but several other predisposing conditions are recognized. We report a case in which urate nephropathy complicated status epilepticus and review the literature regarding previous similar cases. In addition, we discuss current views of the pathophysiology of acute kidney injury due to urate nephropathy. This case illustrates the value of carefully examining the urine of patients with acute kidney injury to identify causes that may have a specific treatment.

Osteoprotegerin inhibits aortic valve calcification and preserves valve function in hypercholesterolemic mice.

BACKGROUND: There are no rigorously confirmed effective medical therapies for calcific aortic stenosis. Hypercholesterolemic Ldlr (-/-) Apob (100/100) mice develop calcific aortic stenosis and valvular cardiomyopathy in old age. Osteoprotegerin (OPG) modulates calcification in bone and blood vessels, but its effect on valve calcification and valve function is not known. OBJECTIVES: To determine the impact of pharmacologic treatment with OPG upon aortic valve calcification and valve function in aortic stenosis-prone hypercholesterolemic Ldlr (-/-) Apob (100/100) mice. METHODS: Young Ldlr (-/-) Apob (100/100) mice (age 2 months) were fed a Western diet and received exogenous OPG or vehicle (N = 12 each) 3 times per week, until age 8 months. After echocardiographic evaluation of valve function, the aortic valve was evaluated histologically. Older Ldlr (-/-) Apob (100/100) mice were fed a Western diet beginning at age 2 months. OPG or vehicle (N = 12 each) was administered from 6 to 12 months of age, followed by echocardiographic evaluation of valve function, followed by histologic evaluation. RESULTS: In Young Ldlr (-/-) Apob (100/100) mice, OPG significantly attenuated osteogenic transformation in the aortic valve, but did not affect lipid accumulation. In Older Ldlr (-/-) Apob (100/100) mice, OPG attenuated accumulation of the osteoblast-specific matrix protein osteocalcin by ∼80%, and attenuated aortic valve calcification by ∼ 70%. OPG also attenuated impairment of aortic valve function. CONCLUSIONS: OPG attenuates pro-calcific processes in the aortic valve, and protects against impairment of aortic valve function in hypercholesterolemic aortic stenosis-prone Ldlr (-/-) Apob (100/100) mice.

Pioglitazone attenuates valvular calcification induced by hypercholesterolemia.

OBJECTIVE: Development of calcific aortic valve stenosis involves multiple signaling pathways, which may be modulated by peroxisome proliferator-activated receptor-γ). This study tested the hypothesis that pioglitazone (Pio), a ligand for peroxisome proliferator-activated receptor-γ, inhibits calcification of the aortic valve in hypercholesteremic mice. METHODS AND RESULTS: Low density lipoprotein receptor(-/-)/apolipoprotein B(100/100) mice were fed a Western-type diet with or without Pio (20 mg/kg per day) for 6 months. Pio attenuated lipid deposition and calcification in the aortic valve, but not aorta. In the aortic valve, Pio reduced levels of active caspase-3 and terminal deoxynucleotidyl transferase dUTP nick end labeling staining. Valve function (echocardiography) was significantly improved by Pio. To determine whether changes in gene expression are associated with differential effects of Pio on aortic valves versus aorta, Reversa mice were fed Western diet with or without Pio for 2 months. Several procalcific genes were increased by Western diet, and the increase was attenuated by Pio, in aortic valve, but not aorta. CONCLUSIONS: Pio attenuates lipid deposition, calcification, and apoptosis in aortic valves of hypercholesterolemic mice, improves aortic valve function, and exhibits preferential effects on aortic valves versus aorta. We suggest that Pio protects against calcific aortic valve stenosis, and Pio or other peroxisome proliferator-activated receptor-γ ligands may be useful for early intervention to prevent or slow stenosis of aortic valves.

Statin therapy reduces growth of abdominal aortic aneurysms.

BACKGROUND: The aim of this study was to evaluate the influence of statins on the growth of small abdominal aortic aneurysms (AAAs). METHODS: We retrospectively examined AAA diameter in 211 patients who had undergone serial imaging surveillance. RESULTS: Patients treated with and without statins were similar regarding age, initial aneurysm size, diagnosis of diabetes and hypertension, and smoking history. Patients receiving statins had a decreased aneurysm growth rate compared with those patients not receiving statins (0.9 mm/y [interquartile range, -1.0 to +1.0] vs 3.2 mm/y [interquartile range, 2.0-4.9], P < 0.0001). This difference in the rate of growth was maintained after adjusting for potential confounding factors. CONCLUSIONS: To date, this is the one of the largest retrospective studies demonstrating an association between statin use and decreased growth rate of AAA.

[Autoimmune thyroid disease. Clinical and biological correlations]. / Maladies thyroïdiennes auto-immunes corrélations cliniques et biologiques.

In this article, we analyze the clinical and biological data concerning the autoimmune thyroid diseases in patients recruited in an endocrinology clinic at the university hospital center of Hôtel-Dieu de France between March 2005 and November 2005. We studied 121 patients (51 with Basedow disease and 70 with Hashimoto thyroiditis), between 13 and 68 years old, with a BMI of 24.68 kg/m2 and with a female predominance (105 women). Symptoms of hyperthyroidism represented the most frequent cause of consultation. The distribution of patients regarding their thyroid disease showed that 42.1% of patients had hyperthyroidism (only one patient had subclinical hyperthyroidism), 21.5% had a subclinical hypothyroidism, 28.1% had clinical hypothyroidism and 8.3% had euthyroid goiter. Half of the patients had at least a member of their family whith a thyroid disease. The autoimmune thyroid diseases are strongly associated to other autoimmune diseases and to repetitive spontaneous abortion. Thus, 39% of the married women had had at least one spontaneous abortion and 26.4% of the patients had one or more autoimmune disease associated to their thyroid disease; diabetes mellitus type 1 representing the most frequent one. Concerning the treatment, we remarked a remission of 30 patients (66.7%) with Basedow disease after 18 months of antithyroid drug treatment of 45 patients. In Hashimoto thyroiditis, we remarked a frequent evolution of patients with subclinical hypothyroidism to overt hypothyroidism when medical treatment was not initiated.

[Colorectal cancer in young patients: presentation, clinicopathological characteristics and outcome]. / Le cancer colorectal du sujet jeune: présentation, caractéristiques clinicopathologiques et pronostic.

UNLABELLED: Previous studies have emphasized the increasing incidence of colorectal cancer (CCR) among young adults and suggest that they may have more aggressive disease and worse five-year survivals than their older counterparts. PURPOSE: Describe the profile of sporadic colorectal cancer in young patients focusing on its prevalence, clinicopathological characteristics, prognostic and survival factors. METHODS: Three hundred and twenty-five CCR patients were divided in two groups : G1 < 45 years and G2 > 45 years. RESULTS: 13.2% of patients were less than 45 years old. A family history of a first-degree relative with colorectal cancer was more frequent in young patients: 44.1% vs 18.2% (p = 0.025). A significant delay in seeking medical care was noted in G1 patients: 29.7 weeks vs 18.6 weeks (p = 0.01). A trend to have more aggressive stages III and IV at presentation was observed among young patients: 55.8% vs 48.6% (p = 0.8). Mucin-producing tumors were more frequently observed in G1 group: 41.9% vs 12% (p = 0.000). Mean survival was 76.9 months in G1 group and 91.7 months in G2 group (p = NS). Five-year survival was 52% in G1 group and 58% in G2 group (p = 0.6). Stage for stage comparison was not significant in determining survival. The only independent factors were delay in consultation, right location of the tumor, peritoneal carcinomatosis, and the need for chemotherapy. CONCLUSION: This study confirms that colorectal cancer in young patients is frequent. Despite more frequent occurrence of mucin-producing tumors, age is not by itself a worse outcome predictor.

[A case of PAN with positive Hbs Ag cured by immunosuppressive and antiviral therapies: a case report]. / Guérison d'un cas de pan avec Ag Hbs positif sous immunosuppresseurs et antiviraux: a propos d'un cas.

Polyarteritis nodosa (PAN) first described by Kussmaul and Maier in 1866, is a multisystem necrotizing vasculitis of small and middle-sized muscular arteries. The presence of hepatitis B antigenemia (Hbs Ag) in approximately 30% of patients with PAN as well as immune complexes of Hbs Ag-Immunoglobulins and complement in the blood vessel walls strongly suggest the role of immunologic phenomena. The extremely poor prognosis of classic PAN has been modified by corticosteroid treatment with boluses of cyclophosphamide, and plasmapheresis. We report a case of PAN with renal, cardiac, central and peripheral nervous system involvement associated with active hepatitis B that got a total remission with corticosteroids, lamivudine and boluses of cyclophosphamide without plasmapheresis.