Systematic review of risk prediction models for diabetes after bariatric surgery.

BACKGROUND: Diabetes remission is an important outcome after bariatric surgery. The purpose of this study was to identify risk prediction models of diabetes remission after bariatric surgery. METHODS: A systematic literature review was performed in MEDLINE, MEDLINE-In-Process, Embase and the Cochrane Central Register of Controlled Trials databases in April 2015. All English-language full-text published derivation and validation studies for risk prediction models on diabetic outcomes after bariatric surgery were included. Data extraction included population, outcomes, variables, intervention, model discrimination and calibration. RESULTS: Of 2330 studies retrieved, eight met the inclusion criteria. Of these, six presented development of risk prediction models and two reported validation of existing models. All included models were developed to predict diabetes remission. Internal validation using tenfold validation was reported for one model. Two models (ABCD score and DiaRem score) had external validation using independent patient cohorts with diabetes remission assessed at 12 and 14 months respectively. Of the 11 cohorts included in the eight studies, calibration was not reported in any cohort, and discrimination was reported in two. CONCLUSION: A variety of models are available for predicting risk of diabetes following bariatric surgery, but only two have undergone external validation.

Ideal versus corrected body weight for dosage of sugammadex in morbidly obese patients.

To date, the dosing of sugammadex is based on real body weight without taking fat content into account. We compared the reversal of profound rocuronium-induced neuromuscular blockade in morbidly obese patients using doses of sugammadex based on four different weight corrections. One hundred morbidly obese patients, scheduled for laparoscopic bariatric surgery under propofol-sufentanil anaesthesia, were randomly assigned four groups: ideal body weight; ideal body weight + 20%; ideal body weight + 40%; and real body weight. Patients received sugammadex 2 mg.kg(-1), when adductor pollicis monitoring showed two responses. The primary endpoint was full decurarisation. Secondary endpoints were the ability to get into bed independently on arrival to the post-anaesthetic care unit and clinical signs of residual paralysis. There was no residual paralysis in any patient. Morbidly obese patients can safely be decurarised from rocuronium-induced neuromuscular blockade T1-T2 with sugammadex dosed at 2 mg.kg(-1) ideal body weight + 40% (p < 0.0001).

Surgical treatment of Barrett's carcinoma. Correlations between morphologic findings and prognosis.

Barrett's carcinoma occurred in 66 of 331 patients with adenocarcinomas of the esophagus or gastroesophageal junction. Only 32 (46%) of these patients had a history of gastroesophageal reflux. A history of alcohol and tobacco abuse was absent in 50% and 47.5%, respectively. The mean length of Barrett's metaplasia was 7.37 cm. Operability was 98.5% and resectability 95.5%. No postoperative or hospital deaths occurred. Pathologic staging was as follows: stage 0 and I, 38.3%; stage II, 20.6%; stage III, 22.2%; and stage IV, 19%. Overall survivals were 80.5% at 1 year, 62.7% at 2 years, and 58.2% at 5 years. Five-year survival for patients with stage I disease was 100%; for stage II, 87.5%; for stage III, 22.2%; and for stage IV, 0%. Thirty-four (51.5%) patients were under surveillance for a related or unrelated condition before diagnosis of their carcinoma; only nine (26.5%) had diseased lymph nodes. In 32 the diagnosis was made at their first medical contact, and 78% of them had diseased lymph nodes. Five-year survival without nodal metastasis was 85.3% and significantly better than for patients with metastasis, 38.3% (p = 0.0033). Of the 66 patients, 19 (28.7%) had a biopsy-proved history of Barrett's metaplasia before malignancy developed. Mean time interval between diagnosis of metaplasia and degeneration was 3.8 years (89.5% > 1 year). Over the surveillance period, the length of metaplastic Barrett's esophagus remained unchanged in all patients. Barrett's ulceration was present from the beginning in 14 patients, and three patients never had an ulcer. Intestinal metaplasia was seen in 18 patients. Resected specimens revealed severe dysplasia in 16 patients. Of the 19 patients, 73.7% had stage I disease. Our data suggest that close endoscopic monitoring and systematic biopsies of the smallest irregularities in the metaplastic mucosa may result in early detection of carcinoma. In this respect, patients with an ulcer within a zone of intestinal metaplasia seem to be at risk. Early detection increases substantially the chances for cure by diminishing the risks of lymph node involvement. Resection remains the treatment of choice in Barrett's adenocarcinoma including high-grade dysplasia, because mortality can be kept low with excellent to very good functional results in the majority of the patients provided the intervention is performed by experienced teams.

Gastric perforation after aortocoronary bypass grafting with the right gastroepiploic artery.

In coronary artery bypass grafting, we prefer the right gastroepiploic artery as an adjunct to the internal mammary arteries, due to its comparable size to the mammary artery, flow, length, freedom of atherosclerosis, pharmacologic responses, and patency rate. No major gastric complications after the use of the gastroepiploic artery have been reported yet. We report gastric perforation due to excessive coagulation of side branches of the gastroepiploic artery supplying the greater curvature of the stomach.

Value of computed tomography and mediastinoscopy in preoperative evaluation of mediastinal nodes in non-small cell lung cancer. A study of 569 patients.

The efficacy of computed tomography (CT) and mediastinoscopy as staging modalities to assess mediastinal lymph node status was evaluated in 569 patients with a presumed resectable non-small cell lung cancer (NSCLC). Computed tomography scan was performed in every patient and followed by mediastinoscopy in 331 and by thoracotomy in 477 patients. Mediastinal lymph nodes on CT larger than 1.5 cm were considered pathological. Overall, CT had a sensitivity of 69%, a specificity of 71% and an accuracy of 71% in identifying mediastinal lymph node metastases. For mediastinoscopy these figures were 72%, 100% and 89%, respectively. Computed tomography accuracy was distinctly lower in squamous cell carcinomas and in central tumors, as CT sensitivity was significantly lower in left-sided tumors. The positive predictive value (PPV) of CT in T1 lesions (29%) and PPV and negative predictive value (NPV) of CT in T2 squamous cell carcinomas (30% and 83%, respectively) were low, so questioning its use in those instances. We perform a mediastinoscopy in every situation except for squamous cell carcinomas or small (less than 3 cm) peripheral tumors in the absence of enlarged mediastinal lymph nodes. This selective attitude is rewarding since a) the number of pN2 in the straight thoracotomy group was only 16% versus 41% in the mediastinoscopy group, b) the exploratory thoracotomy rate in the straight thoracotomy group was low (4.6%).

Thoracoscopic-assisted pulmonary resection in lung cancer.

BACKGROUND: Thoracoscopic-assisted pulmonary resection for lung cancer is controversial. The appropriateness of this approach has to be compared with the golden standard of an open resection. METHODS: This study consists of 66 patients with a clinical stage 1 disease. A thoracoscopic exploration was executed in 41 patients. Only in 16 cases was a thoracoscopic resection finally possible. The clinical and pathological TNM classification, the histological types and the surgical procedure are reported. The reasons for conversion are documented. RESULTS: To investigate the appropriateness of the thoracoscopic approach we evaluated only the pathologically proven stage 1 disease in both groups. Postoperative complications, hospital stay and survival are compared. CONCLUSION: Until now we can conclude that there is no adverse effect on survival because of the thoracoscopic approach.

Epitheloid angiosarcoma of the splenic capsula as a result of foreign body tumorigenesis. A case report.

A case of an epitheloid angiosarcoma of the splenic capsula is reported. This tumour developed in close relation to a gauze sponge, which was accidentally left behind 38 years earlier during a left-sided nephrectomy. The tumour probably arose from pluripotential mesothelial stem cells within the splenic capsula, with subsequent mesothelial to endothelial metaplasia and neoplastic transformation. Clinical, radiological, peroperative and pathological features of this angiosarcoma add to the validity of the concept of inert foreign body tumorigenesis.

Epidermoid cysts of the spleen.

Primary nonparasitic splenic cysts are very rare. Clinical manifestations vary but are often not very typical. Ultrasound and computed tomography are of use for establishing diagnosis. A microscopic examination of the surgical specimen is the only way to make the diagnosis of an epidermoid cyst. The histological characteristic of an epidermoid cyst is the presence of an epidermoid epithelial cyst lining of the inner surface. Treatment requires surgery and is necessary to prevent serious complications. Spleen saving surgical procedures are advocated. We present two cases of young patients with a large epidermoid cyst of the spleen who were operated on. On one patient, we had to perform a splenectomy because of the size and central localization of the cyst with compression of the splenic pedicle. On the other patient we managed to perform a partial splenectomy.

The laparoscopic resection of a benign stromal tumour of the duodenum.

A 72-year-old-female presented intermittent retrosternal pain, heartburn and dysphagia. Computerized CT-Scan showed a large mass with a cross-sectional diameter of 5 cm at the lateral side of part II of the duodenum. The preoperative histology was unclear. The tumour was successfully removed by laparoscopic approach.

The laparoscopic approach of a torsion of a benign mature ovarian teratoma: a case report and review of the literature.

Benign mature teratomas account for approximately 10-15% of all ovarian neoplasms. Many patients with these dermoid cysts are asymptomatic. The most frequent complication is torsion of the teratoma (in 3,5% of the cases). In a 26-year female patient admitted for severe, acute abdominal pain, a computerized abdominal tomography in accordance with the clinical characteristics of the abdominal examination, was highly suggestive for a torsion of a teratoma. The diagnose was confirmed by a celioscopic operative approach and the teratoma with the left tubo-ovarian complex was successfully removed laparoscopically.