Survival of advanced/recurrent gastrointestinal stromal tumors treated with tyrosine kinase inhibitors in Taiwan: a nationwide registry study.

BACKGROUND: Most gastrointestinal stromal tumors (GISTs) harbor c-KIT or PDGFRA mutations. Administration of tyrosine kinase inhibitors (TKIs) has significantly improved the survival of patients with GISTs. We aimed to evaluate the clinical outcome of advanced or recurrent GIST patients in Taiwan. METHODS: Patients diagnosed between 2010 and 2020 were enrolled. The collected data included baseline characteristics, treatment pattern, treatment outcome, genetic aberrations and survival status. Progression-free survival (PFS) and overall survival (OS) were analyzed and plotted with the Kaplan-Meier method. Cox regression analysis was used to analyze the prognostic factors of survival. RESULTS: A total of 224 patients with advanced or recurrent GISTs treated with TKIs were enrolled. All patients received imatinib treatment. Ninety-three and 42 patients received sunitinib and regorafenib treatment, respectively. The 48-month PFS and OS rates for patients treated with imatinib were 50.5% and 79.5%, respectively. c-KIT exon 9 and PDGFRA mutations were prognostic factors for a poor PFS and PDGFRA mutation was a prognostic factor for a poor OS in patients treated with imatinib in multivariate Cox regression analysis. The median PFS of patients who received sunitinib treatment was 12.76 months (95% confidence interval (CI), 11.01-14.52). Patients with c-KIT exon 9 mutations had a longer PFS than those with other genetic aberrations. The median PFS of patients treated with regorafenib was 7.14 months (95% CI, 3.39-10.89). CONCLUSIONS: We present real-world clinical outcomes for advanced GIST patients treated with TKIs and identify mutational status as an independent prognostic factor for patient survival.

Comparison of safety, efficacy, and patient satisfaction with thermal ablation versus endoscopic thyroidectomy for benign thyroid nodules in a propensity-matched cohort.

BACKGROUND: Thyroid nodules (TNs) often require intervention due to symptomatic or cosmetic concerns. Radiofrequency ablation (RFA) has shown promise as a treatment option, offering potential advantages without neck scars. Recently, the scarless treatment alternative of transoral endoscopic thyroidectomy vestibular approach (TOETVA) has emerged. When surgery can be performed in a scarless manner, it remains unclear whether ablation is still the preferred treatment choice. This study aims to compare the safety, efficacy, and patient satisfaction of RFA and TOETVA. STUDY DESIGN: A retrospective data analysis was conducted on patients treated with RFA or TOETVA for unilateral benign TNs between December 2016 and September 2021. Propensity score matching was employed to create comparable groups. Various clinicopathologic parameters, treatment outcomes, and costs were assessed. RESULTS: Of the 2814 nonfunctional thyroid nodules treated during this period, 642 were benign and unilateral. A total of 121 and 100 patients underwent thermal ablation and transoral endoscopic thyroidectomy, respectively. After matching, 84 patients were selected for each group. Both RFA and TOETVA demonstrated low complication rates, with unique complications associated with each procedure. Treatment time (30.8±13.6 vs. 120.7±36.5 min, P <0.0001) was shorter in the RFA group. Patient satisfaction (significant improvement: 89.3% vs. 61.9%, P <0.0001) and cosmetic results (cosmetic score 1-2: 100.0% vs. 54.76%, P <0.0001) favored TOETVA. RFA was found to be less costly for a single treatment, but the cost of retreatment should be considered. The histological diagnoses post-TOETVA revealed malignancies in 9 out of 84 cases, underscoring the significance of follow-up assessments. CONCLUSION: Scarless procedures, RFA and TOETVA, are effective for treating unilateral benign TNs, each with unique advantages and drawbacks. While RFA is cheaper for a single treatment, TOETVA offers superior cosmetic results and patient satisfaction. Further research is needed to evaluate long-term safety and cost-effectiveness. It is crucial to remain vigilant about the possibility of malignancy despite benign cytology pre-treatment.

Synergic evacuation device helps smoke control during endoscopic thyroid surgery.

BACKGROUND: Surgical plumes in small cavities, such as transoral endoscopic thyroid surgery, have never been satisfactorily resolved. We aimed to study the use of a smoke evacuation system and evaluate its efficacy, including the field of view and operating time. STUDY DESIGN: We retrospectively reviewed 327 consecutive patients who underwent endoscopic thyroidectomy. They were separated into 2 groups based on whether the smoke evacuation system was used. To reduce the possible experience bias, only patients 4 months before and after implementing the evacuation system were included. Recorded endoscopic videos were evaluated, including the field of view, the incidence of scope clearance, and time spent during air-pocket creation. RESULTS: Overall, there were 64 patients with a median age of 43.59 years and a median body mass index of 22.87 kg/m2, including 54 women, 21 thyroid cancers, and 61 hemithyroidectomies. The operative duration was comparable between the groups. The group where the evacuation system was used scored more as good in terms of endoscopic views (8/32, 25% vs 1/32, 3.13%, P = .01), fewer incidences of endoscope lens pull out for clearance (3.5 vs 6.0 times, P < .01), less time for clear view after energy device activation (2.67 vs 5.00 seconds, P < .01), and less time spent (8.67 vs 12.38 minutes, P < .01) during air-pocket creation. CONCLUSION: In conjunction with the synergy function of energy devices, evacuators enhance the field of view and optimize the time spent in the real clinical setting of low-pressure and small-space endoscopic thyroid procedures, in addition to the benefit of reducing smoke harm.

Chemical composition of smoke produced by open versus laparoscopic surgery for cholecystectomy.

BACKGROUND: Smoke produced by traditional open surgery (TOS) has long been considered hazardous to medical staff. Compared with TOS, minimally invasive surgery under carbon dioxide pneumoperitoneum is associated with a faster recovery and less wound pain. However, the impact of oxygen-deficient environment on the chemical contents of smoke has not been comprehensively assessed. METHODS: This research evaluated the chemical composition and volatile organic compound (TVOC) level in smoke produced by open cholecystectomy (OC) versus laparoscopic cholecystectomy (LC) for gallbladder diseases. Smoke samples were collected and analyzed via gas chromatography-mass spectrometry. Chemical compounds were further grouped according to molecular weight and toxicity. RESULTS: Compared with the OC, LC had significantly higher halocarbon and TVOC levels but lower cycloalkene and aldehyde levels. No halocarbons were isolated from OC specimens. When stratified based on molecular weight, LC had a bimodal pattern (i.e., high levels of small-sized [<60 Da] and large-sized [>120 Da] compounds). There was no difference in terms of toxicity types, incidence, and severity associated with detected compounds between two groups. CONCLUSION: LC is associated with a higher TVOC level and proportion of low- and high-molecular-weight organic compounds. Further strategies of evacuating these health hazards and preventing smoke leakage through trocars should be considered.

Intravenous Arginine Administration Attenuates the Inflammatory Response and Improves Metabolic Profiles in Diet-Induced Obese Mice after Sleeve Gastrectomy.

Sleeve gastrectomy (SG) is a bariatric surgery that can effectively reduce weight and improve obesity-associated comorbidities. However, surgical stress intensifies inflammation and imbalanced metabolic profiles. Arginine (Arg) is a nutrient with immunomodulatory and anti-inflammatory properties. This study evaluated the short-term effects of Arg administration on adipocyte inflammation and metabolic alterations in obese mice after SG. Mice were assigned to normal and high-fat diet (HFD) groups. After 16 weeks, the HFD group were divided to sham (SH), SG with saline (SS), or Arg (SA) groups. SS and SA groups were postoperatively injected with saline or Arg via the tail vein and sacrificed at day 1 or 3 after the SG, respectively. Results showed that obesity caused elevated plasma glucose and leptin levels. The SG operation enhanced the expression of inflammatory cytokines and macrophage infiltration in adipose tissues, whereas hepatocyte gene expressions associated with lipid ß-oxidation were downregulated. Arg treatment reversed the expressions of ß-oxidation-associated genes and reduced lipid peroxide production in the liver. Additionally, adipose tissue expressions of inflammatory chemokines were reduced, while the M2 macrophage marker increased after surgery. The findings suggest that postoperative Arg administration elicited more balanced hepatic lipid metabolism, polarized macrophages toward the anti-inflammatory type, and attenuated adipocyte inflammation shortly after SG.

Characteristics and outcomes of second cancers in patients with childhood cancer: A report from the Taiwan Pediatric Oncology Group.

BACKGROUND: Patients with childhood cancer are at increased risk for the development of second cancers. METHODS: A national multicenter survey of second cancers conducted by the Taiwan Pediatric Oncology Group retrieved retrospective data from the database at the Children Cancer Foundation in Taiwan beginning in 1995. The characteristics of second cancers and associations of patient demographic and clinical characteristics with time to death due to a second cancer were analyzed. RESULTS: We examined the records of 8782 patients with a primary cancer diagnosed between January 1, 1995 and December 31, 2013, and a total of 99 patients with a second cancer were identified. The most common type of second cancer was acute myeloid leukemia (n = 35), followed by acute lymphoblastic leukemia (n = 15), central nervous system (CNS) tumors (n = 15), and sarcomas (n = 10). Secondary hematological malignancies occurred earlier than other secondary cancers. The frequencies of second CNS tumors and second bone cancers and sarcomas were notably increased when prior radiation doses increased from zero, low dose to high dose. The overall 5-year survival of patients with a second cancer was poor (33.7%). Multivariate survival analysis revealed that the year of primary diagnosis ≤2002, secondary hematological malignancies, and age at second cancer diagnosis ≤9.3 years or >26.8 years increased the risk of death following second cancer. CONCLUSION: Children who develop a second cancer have an unfavorable outcome. Early detection and improved treatment for second cancers are needed.

Predictors of diabetes relapse after metabolic surgery in Asia.

BACKGROUND: Limited studies have focused on diabetes relapse after metabolic surgery, especially among Asians. OBJECTIVES: To identify the predictors of diabetes relapse following initial postoperative remission in Asia. SETTING: Four tertiary hospitals METHODS: We assessed 342 patients (age, 41.0 ± 10.8 yr; body mass index [BMI], 39.6 ± 7.3 kg/m2) with complete diabetes data before and 1 and 3 years after metabolic surgery. A total of 290 (84.8%) and 277 (81.0%) patients had diabetes remission at 1 and 3 years after surgery. Logistic regressions were performed to identify the independent predictors of diabetes relapse. Two published predictive models for diabetes remission were also tested for relapse. RESULTS: Of the 290 patients with 1-year diabetes remission, 29 (10%) experienced a relapse at 3 years after surgery. The area under the receiver operating characteristic curve of the ABCD score in predicting 1-year remission, 3-year remission, and 3-year relapse were .814, .793, and .795, while those of the DiaRem2 score were .823, .774, and .701, respectively. The baseline age, BMI, and insulin use were independent predictors for relapse. The most powerful predictive model for relapse was composed of preoperative insulin use, 1-year A1C, and a change in BMI between the first and third year (C-statistic: .919). CONCLUSION: The ABCD score predicted both mid-term postoperative diabetes remission and relapse in Asians. Initial older age, lower BMI, insulin use, higher 1-year A1C, and weight regain were independent predictors of relapse. Personalized strategies should be proposed for those at risk of relapse to optimize diabetes outcomes after surgery.

Protective Effects of Glutamine and Leucine Supplementation on Sepsis-Induced Skeletal Muscle Injuries.

This study investigated the effects of l-glutamine (Gln) and/or l-leucine (Leu) administration on sepsis-induced skeletal muscle injuries. C57BL/6J mice were subjected to cecal ligation and puncture to induce polymicrobial sepsis and then given an intraperitoneal injection of Gln, Leu, or Gln plus Leu beginning at 1 h after the operation with re-injections every 24 h. All mice were sacrificed on either day 1 or day 4 after the operation. Blood and muscles were collected for analysis of inflammation and oxidative damage-related biomolecules. Results indicated that both Gln and Leu supplementation alleviated sepsis-induced skeletal muscle damage by reducing monocyte infiltration, calpain activity, and mRNA expression levels of inflammatory cytokines and hypoxia-inducible factor-1α. Furthermore, septic mice treated with Gln had higher percentages of blood anti-inflammatory monocytes and muscle M2 macrophages, whereas Leu treatment enhanced the muscle expressions of mitochondrion-related genes. However, there were no synergistic effects when Gln and Leu were simultaneously administered. These findings suggest that both Gln and Leu had prominent abilities to attenuate inflammation and degradation of skeletal muscles in the early and/or late phases of sepsis. Moreover, Gln promoted the switch of leukocytes toward an anti-inflammatory phenotype, while Leu treatment maintained muscle bioenergetic function.

Practice Patterns and Learning Curve in Transoral Endoscopic Thyroidectomy Vestibular Approach With Neuromonitoring.

Objectives: Intraoperative neuromonitoring has not been routinely applied in early experience with the transoral endoscopic thyroidectomy vestibular approach (TOETVA). Because the preparation and surgical interventions are much different from conventional thyroidectomies, most endocrine surgeons willing to adapt to TOETVA lack access to information regarding the practice pattern and proficiency in the learning curve. We aimed to investigate the outcomes and to define the learning curve for TOETVA in this study. Methods: A retrospective analysis was used on patients who underwent TOETVA at our hospital between December 2016 and July 2019. The cumulative sum graphic model was used to implement the learning curve as a surrogate for procedural proficiency. Results: The 119 patients had a mean age of 44.65 years and a mean body mass index of 22.49 k/m2, including 107 women, 20 thyroiditis, and 106 hemithyroidectomy. The learning curve revealed two phases, an initial (35 cases) and a mature (84 cases) phase, for surgeons based on operation time (144.2 vs. 114.2 min, p = 0.0001). There were more bilateral thyroidectomies (15.5% vs. 0, p = 0.0100), larger indicated nodules (6.06 cm3vs. 3.32 cm3, p = 0.0468), or larger thyroids to resect (16.38 cm3vs. 8.75 cm3, p = 0.0001) in the mature phase. Procedure-related complications decreased significantly in the mature phase in comparison to the initial phase (3.57% vs. 31.43%, p = 0.0001). Conclusions: The learning curve of TOETVA with neuromonitoring is 35 cases. With the accumulation of proficiency, the indications will expand. Step-by-step improvements from the experience of each case can reduce procedure-related complications.

Early weight loss as a predictor of 3-year weight loss and weight regain in patients with good compliance after sleeve gastrectomy.

BACKGROUND: Sleeve gastrectomy (SG) is the most common surgery for severe obesity. Patients lose weight post SG and regain some weight in the following years. Early weight loss predicts weight loss after SG. However, etiologies of weight loss and regain after SG remain unclear. OBJECTIVES: To investigate the effects of early weight loss on medium-term weight regain post SG. SETTING: Two university hospitals in Taiwan. METHODS: Patients with records within 1 and at 3 years after SG were enrolled retrospectively. Preoperative clinical variables and percentage of total weight loss (%TWL) were analyzed. Weight regain was defined as a weight increase from 1 year postoperatively of >25% of the lost weight. Linear and multiple logistic regression were applied to examine the associations of early weight loss, weight loss, and weight regain. RESULTS: A total of 363 patients were included. Body mass indexes before and 1, 3, 6, 12, and 36 months postoperatively were 40.7 ± 6.8 kg/m2, 36.6 ± 6.2 kg/m2, 33.5 ± 5.8 kg/m2, 30.9 ± 5.5 kg/m2, 28.4 ± 5.2, and 29.3 ± 5.4 kg/m2, respectively. At 3 years after SG, 73 patients (20.1%) had weight regain. In multivariate linear analyses, initial age, waist circumference, type 2 diabetes, and %TWL at 1 or 3 months were associated with either 1-year or 3-year %TWL. Multiple logistic regression revealed %TWL at 3 months to be a predictor for 3-year weight regain after SG (odds ratio, .927; P = .02). CONCLUSION: Early weight loss predicted weight loss and regain 3 years after SG. Early lifestyle and behavioral interventions are suggested in patients at high risk of poor weight loss and weight regain outcomes after SG.

Glutamine Administration Attenuates Kidney Inflammation in Obese Mice Complicated with Polymicrobial Sepsis.

Obesity is a well-known public health issue around the world. Sepsis is a lethal clinical syndrome that causes multiorgan failure. Obesity may aggravate inflammation in septic patients. Glutamine (GLN) is a nutrient with immune regulatory and anti-inflammatory properties. Since sepsis is a common contributing factor for acute kidney injury (AKI), this study investigated the effects of GLN administration on sepsis-induced inflammation and AKI in obese mice. A high-fat diet which consists of 60% of calories from fat was provided for 10 weeks to induce obesity in the mice. Then, the obese mice were subdivided into sepsis with saline (SS) or GLN (SG) groups. Cecal ligation and puncture (CLP) was performed to produce sepsis. The SS group was intravenously injected with saline while the SG group was administered GLN one or two doses after CLP. Obese mice with sepsis were sacrificed at 12, 24, or 48 h post-CLP. Results revealed that sepsis resulted in upregulated high-mobility group box protein-1 pathway-associated gene expression in obese mice. Also, expressions of macrophage/neutrophil infiltration markers and inflammatory cytokines in kidneys were elevated. Obese mice treated with GLN after sepsis reversed the depletion of plasma GLN, reduced production of lipid peroxides, and downregulated macrophage/neutrophil infiltration and the inflammatory-associated pathway whereas tight junction gene expression increased in the kidneys. These findings suggest that intravenously administered GLN to obese mice after sepsis alleviated inflammation and attenuated AKI. This model may have clinical application to obese patients with a risk for infection in abdominal surgery.

Treatment outcomes of pediatric acute myeloid leukemia: a retrospective analysis from 1996 to 2019 in Taiwan.

Improvement in outcomes of children with acute myeloid leukemia (AML) is attributed to several refinements in clinical management. We evaluated treatment outcomes of Taiwanese pediatric AML patients in the past 20 years. Overall, 860 de novo AML patients aged 0-18 years and registered in the Childhood Cancer Foundation of R.O.C during January 1996-December 2019 were included. Survival analysis was performed to identify factors that improved treatment outcomes. Regardless of treatment modalities used, patients during 2008-2019 had better 5-year event-free survival (EFS) and overall survival (OS) rates than patients during 1996-2007. For patients received the TPOG-AML-97A treatment, only 5-year OS rates were significantly different between patients diagnosed before and after 2008. Patients with RUNX1-RUNX1T1 had similar relapse-free survival rates, but 5-year OS rates were better during 2008-2019. However, the survival of patients who received hematopoietic stem-cell transplantations (HSCT) did not differ significantly before and after 2008. For patients without relapse, the 5-year OS improved during 2008-2019. Non-relapse mortality decreased annually, and cumulative relapse rates were similar. In conclusion, 5-year EFS and OS rates improved during 2008-2019, though intensities of chemotherapy treatments were similar before and after 2008. Non-relapse mortality decreased gradually. Further treatment strategies including more intensive chemotherapy, novel agents' use, identification of high-risk patients using genotyping and minimal residual disease, early intervention of HSCT, and antibiotic prophylaxis can be considered for future clinical protocol designs in Taiwan.

Parenteral glutamine supplementation improves serum albumin values in surgical cancer patients.

INTRODUCTION: Patients with gastric adenocarcinoma (GA) often develop malnutrition, which deteriorates after cancer surgery and negatively affects surgical outcomes. Despite being an abundant and versatile amino acid involved in the immune system and metabolic functions, glutamine levels are significantly depleted among patients who are critically ill or hypercatabolic. Therefore, this study aimed to investigate whether parenteral glutamine supplementation may improve nutritional status and surgical outcomes. METHODS: This retrospective, single-center cohort study included patients with GA who underwent gastrectomy between January 2007 and June 2019. Patients were classified into either the non-glutamine or glutamine group. Propensity score matching was used to minimize the bias in patient demographics. Furthermore, the average parenteral glutamine dose from the day of surgery to postoperative day four was calculated in g/kg/day. Surgical outcomes (length of hospitalization, major complication, and mortality) and changes in lymphocyte count and serum albumin levels 7 days post-surgery were assessed in both matched groups using adjusted models. RESULTS: A total of 1950 patients were reviewed, among whom 522 (26.8%) received parenteral glutamine supplementation (glutamine dose ranging from 0.05 to 0.49 g/kg/day). Among the included patients, 57.2% were males, and the median age was 64.9 years. After matching, there were 478 cases in each group. No differences in surgical outcomes and changes in lymphocyte count were observed between both matched groups. The glutamine group exhibited a smaller decrease in serum albumin levels compared to the non-glutamine group (-0.6 vs. -1.1 g/dL; P < 0.001). The adjusted matched model showed that glutamine dose contributed significantly toward increasing serum albumin levels (coefficient = 0.08 per 0.1 g/day/kg increment in glutamine; 95% confidence interval: 0.04 to 0.10; P < 0.001). CONCLUSIONS: Perioperative parenteral glutamine supplementation had a positive dose-dependent impact on the recovery of serum albumin levels among patients with GA undergoing gastrectomy, implying that glutamine supplementation improved postoperative nutritional suppression and ameliorated stress-associated inflammation. Although glutamine supplementation was not associated with surgical outcomes, further studies should be conducted to evaluate the clinical significance of serum albumin restoration.

Effects of the Glutamine Administration on T Helper Cell Regulation and Inflammatory Response in Obese Mice Complicated with Polymicrobial Sepsis.

This study investigated the impacts of GLN on inflammation and T cell dysregulation in obese mice complicated with sepsis. Mice were divided into normal control (NC) and high-fat diet groups. The high-fat diet provided 60% of energy from fat and was administered for 10 weeks to induce obesity. Mice fed with a high-fat diet were then assigned to sham (SH) and sepsis with saline (SS) or GLN (SG) groups. The SH group was subjected to laparotomy, while the sepsis group underwent cecal ligation and puncture (CLP). The SS group was intravenously injected with saline. The SG group was intravenously administered GLN after CLP. Mice were sacrificed at 12, 24, or 48 h post-CLP, respectively. Results demonstrated that in the presence of obesity, sepsis drove CD4+ T cells toward the helper T (Th)2 and Th17 lineages. Also, expressions of inflammatory cytokines and macrophage infiltration markers in adipose tissues and lungs were elevated. Treatment of obese mice with GLN after sepsis reversed Th polarization and downregulated macrophage infiltration and inflammatory cytokine, whereas the tight junction-associated protein expression increased in the lungs. These findings suggest that the intravenous administration of GLN to obese mice after sepsis modulated a more balanced Th cell lineage, alleviated inflammation, and attenuated lung injury.

Percutaneous embolization for a subacute gastric fistula following laparoscopic sleeve gastrectomy: a case report and literature review.

BACKGROUND: The management for subacute or chronic fistula after bariatric surgery is very complicated and with no standard protocol yet. It is also an Achilles' heel of all bariatric surgery. The aim of this case report is to describe our experience in managing this complication by percutaneous embolization, a less commonly used method. CASE PRESENTATION: A 23-year-old woman with a body mass index of 35.7 kg/m2 presented with delayed gastric leak 7 days after laparoscopic sleeve gastrectomy (LSG) for weight reduction. Persistent leak was still noted under the status of nil per os, nasogastric decompression, and parenteral nutrition for 1 month; therefore, endoscopic glue injection was performed. The fistula tract did not seal off, and the size of pseudocavity enlarged after gas inflation during endoscopic intervention. Subsequently, we successfully managed this subacute gastric fistula via percutaneous fistula tract embolization (PFTE) with removal of the external drain 2 months after LSG. CONCLUSIONS: PFTE can serve as one of the non-invasive methods to treat subacute gastric fistula after LSG. The usage of fluoroscopy-visible glue for embolization can seal the fistula tract precisely and avoid the negative impact from gas inflation during endoscopic intervention.

Intravenous Glutamine Administration Improves Glucose Tolerance and Attenuates the Inflammatory Response in Diet-Induced Obese Mice after Sleeve Gastrectomy.

Obesity is a health problem associated with many metabolic disorders. Weight reduction can effectively alleviate obesity-associated complications. Sleeve gastrectomy is a commonly used bariatric surgery and is considered safe and effective for improving outcomes. Glutamine (GLN) is an amino acid with anti-oxidative and anti-inflammatory properties. This study used a mouse model of sleeve gastrectomy to investigate the impacts of intravenous GLN administration on glucose tolerance and adipocyte inflammation short-term after surgery. C57BL6 male mice were divided into normal control (NC) and high-fat diet groups. The high-fat diet provided 60% of energy from fat for 10 weeks to induce obesity. Mice fed the high-fat diet were then assigned to a sham (SH) or sleeve gastrectomy with saline (S) or GLN (G) groups. The S group was intravenously injected with saline, while the G group was administered GLN (0.75 g/kg body weight) via a tail vein postoperatively. Mice in the experimental groups were sacrificed on day 1 or 3 after the surgery. Results showed that obesity resulted in fat accumulation, elevated glucose levels, and adipokines production. Sleeve gastrectomy aggravated expressions of inflammatory cytokine and macrophage infiltration markers, cluster of differentiation 68 (CD68), epidermal growth factor-like module-containing mucin-like hormone receptor-like 1 (EMR-1), and macrophage chemoattractant protein-1, in adipose tissues. Treatment of obese mice with GLN downregulated hepatic proteomic profiles associated with the gluconeogenesis pathway and improved glucose tolerance. Moreover, macrophage infiltration and adipose tissue inflammation were attenuated after the sleeve gastrectomy. These findings imply that postoperative intravenous GLN administration may improve glucose tolerance and attenuate inflammation shortly after the bariatric surgery in subjects with obesity.

Derangement of esophageal anatomy and motility in morbidly obese patients: a prospective study based on high-resolution impedance manometry.

BACKGROUND: Morbidly obese patients often suffer from gastroesophageal reflux disease (GERD). High-resolution impedance manometry (HRIM) allows a comprehensive evaluation of esophageal motility and esophagogastric junction (EGJ) morphology and helps to clarify GERD pathophysiology. OBJECTIVE: To evaluate the esophageal function and EGJ anatomy in morbid obesity by HRIM. SETTING: University Hospital, Taiwan. METHODS: We consecutively enrolled 57 morbidly obese patients planning to undergo bariatric surgery and 58 healthy volunteers in this prospective study. All patients responded to validated symptom questionnaires and underwent fasting blood tests, HRIM, and esophagogastroduodenoscopy. We compared anthropometric and HRIM parameters between the 2 groups, and analyzed correlations between the GERD symptom scores and clinical variables in the obese patients. RESULTS: The obese patients, comprising 30 males (53%), had a median age of 35 years and body mass index of 40.5 kg/m2. The 4-second integrated relaxation pressure in the lower esophageal sphincter was significantly higher in the patients than the volunteers (median: 10.8 versus 5.6 mm Hg; P < .001). EGJ outflow obstruction and ineffective esophageal motility were diagnosed in 16% and 11% of the patients, respectively, versus 5% and 28% of the volunteers (P = .022). Manometric hiatal hernia (m-HH) was present in 19 (33%) of the patients and none of the volunteers; all m-HH were associated with erosive esophagitis. Most of the patients were considered as no GERD by the validated questionnaires, regardless of the presence of m-HH and erosive esophagitis. CONCLUSIONS: The obese patients had a higher lower esophageal sphincter 4-second integrated relaxation pressure and higher prevalence of EGJ outflow obstruction and m-HH than the healthy volunteers. The presence of m-HH was strongly associated with erosive esophagitis. The absence of GERD symptoms in morbid obesity was not necessarily suggestive of negative esophagogastroduodenoscopy and HRIM findings, and the discrepancy existed between esophagogastroduodenoscopy and HRIM for diagnosing HH. A comprehensive evaluation of the EGJ anatomy and esophageal function may be considered before bariatric surgery.

Impact of 3D-CT-Based Gastric Wall Volume on Weight Loss after Laparoscopic Sleeve Gastrectomy.

PURPOSE: There are several debates on the association between gastric anatomy and weight loss after laparoscopic sleeve gastrectomy (LSG). There is a paucity of data on the impact of gastric wall volume (GWV) on weight loss. This study therefore aimed to investigate the effect of GWV on weight loss response after LSG. MATERIALS AND METHODS: Thirty-two patients with body mass index (BMI) of ≧ 40 kg/m2 who underwent LSG between November 2016 and August 2018 were enrolled. Three-dimensional computed tomography (3D-CT) was performed pre-operatively and 1 year after LSG to assess gastric volumes. The population was divided into two groups: the first 20% (n = 7) with the largest GWV, defined as LGWV group, and the rest of the population (n = 25), defined as the small GWV (SGWV) group. Percentage total weight loss (%TWL) was compared. RESULTS: The mean preoperative GWV was 216.9 ± 47.7 ml in the SGWV group, versus 336.3 ± 24.1 ml in the LGWV group. Patients with LGWV had significantly lower 1-year %TWL (34.9.1% versus 27.9%, p = 0.0439). Multilinear regression identified LGWV as a significant prognostic factor after adjusting for BMI and early weight loss response. Repeated measure mixed effect model showed that the LGWV group had a significantly slower %TWL change, particularly after 3 months postoperatively. No association was found between 1-year %TWL and preoperative and postoperative gastric luminal volume or resected gastric volume. CONCLUSION: 3D-CT disclosed GWV, but not other gastric anatomical characteristics, was an independent predictor of %TWL after 1-year post LSG.

Circulating Diabetic Candidate Neurotrophic Factors, Brain-Derived Neurotrophic Factor and Fibroblast Growth Factor 21, in Sleeve Gastrectomy.

Recent studies show brain-derived neurotrophic factor (BDNF) and fibroblast growth factor 21 (FGF21) are neurotrophic factors associated with obesity and diabetes mellitus (DM). Laparoscopic sleeve gastrectomy (LSG) can significantly reduce weight and improve DM. In this study, we enrolled 78 patients with obesity and evaluated the change of BDNF and FGF21 6 months after LSG. At baseline, the BDNF level was similar between the preoperative DM (n = 30) (17.1 ± 7.7 ng/ml) and non-DM (n = 48) (17.0 ± 6.9 ng/ml) patients with obesity, but FGF21 was significantly higher in the DM patients (201.5 ± 204.3 versus 107.6 ± 63.8 pg/ml). At 6 months after LSG, most of the preoperative DM patients (96.7%) had DM either resolved (66.7%) or improved (30%). BDNF increased and FGF21 decreased significantly regardless of the preoperative DM status, while FGF21 decreased more prominently in the preoperative DM patients (-92.6 ± 179.8 versus -4.6 ± 63.4 pg/ml). After adjusted for age, sex, and preoperative DM status, FGF21 became significantly and positively related to C-peptide (ß = 18.887), insulin (ß = 2.399), and homeostasis model assessment of insulin resistance index (ß = 8.566) after surgery. In conclusion, diabetic patients with obesity had higher FGF21 and similar BDNF levels compared to non-diabetic obese patients. BDNF increased and FGF21 decreased significantly after LSG. FGF21 became positively associated with several insulin-related profiles after surgery.

Effects of specific nutrients on immune modulation in patients with gastrectomy.

Gastric cancer (GC) is one of the most prevalent and lethal malignant neoplasms worldwide. The main treatment for GC is gastrectomy, which generally causes considerable metabolic stress to patients. To modulate cell function, maintain homeostasis of the immune response, reduce postoperative complications, and obtain favorable outcomes, physicians prescribe specific nutrients with immunomodulatory properties as supplementation to enteral or parenteral formulas, indicating immunonutrition. In the formulas, among the immunonutrients, glutamine, arginine, and n-3 polyunsaturated fatty acids are the most commonly used either alone or in combination. The present review summarizes and focuses on the evidence obtained from clinical trials and animal studies supporting the role of immunonutrients supplemented enterally or parenterally in total or subtotal gastrectomy. In addition, this review describes the possible molecular mechanisms underlying the protective action of these immunonutrients, which may contribute to therapeutic approaches to improve postoperative outcomes of gastrectomy. Combination of conventional therapy with immunonutrition seems to be a useful strategy to achieve synergistic effects in the treatment of GC patients.