The influence of biphasic positive airway pressure vs. sham biphasic positive airway pressure on pulmonary function in morbidly obese patients after bariatric surgery.

BACKGROUND: The effect of biphasic positive airway pressure (BPAP) at individualized pressures on the postoperative pulmonary recovery of morbidly obese patients (MOP) undergoing open bariatric surgery (OBS) and possible placebo device-related effects (sham BPAP) were investigated. METHODS: Forty-eight MOP scheduled for OBS were initially enrolled. Subjects were randomly assigned to: A) the BPAP group in which BPAP, at individualized inspiratory positive airway pressure/expiratory positive airway pressure (IPAP/EPAP), was applied for 3 days postoperatively and B) the sham BPAP group in which sham BPAP was applied for the same time. Pulmonary function was assessed by spirometry 24 h prior to surgery and at 24, 48 and 72 h postoperatively and respiratory complications were recorded. RESULTS: Thirty-five subjects, 21 in the BPAP group and 14 in the sham BPAP group, completed the study. Baseline characteristics and pulmonary function were similar between groups preoperatively. Subjects in the BPAP group showed in general better spirometric performance and SpO2 values postoperatively and expedited pulmonary recovery. Atelectasis combined with respiratory distress syndrome (RDS) symptoms was observed in 21% of subjects in the sham BPAP group and one of these subjects developed lower respiratory tract infection. No respiratory complications were recorded in the BPAP group. Use of higher BPAP pressures was not associated with anastomosis leakage or disruption in any patient. CONCLUSION: Use of BPAP, at individualized pressures, expedites postoperative pulmonary recovery and eliminates respiratory complications in MOP who have undergone OBS.

Mixed large cell neuroendocrine carcinoma with squamous cell carcinoma of the rectum: Report of a rare case and review of the literature.

INTRODUCTION: Mixed large cell neuroendocrine neoplasms of the rectum are rare and aggressive neoplasms. Survival is poor due to the high rate of lymph node metastases and distant metastases at the time of diagnosis. PRESENTATION OF CASE: We report a case of a 50-year-old male patient with a mixed large cell neuroendocrine carcinoma with squamous cell carcinoma of the rectum located 8cm from the anal verge, treated with low anterior resection and total mesorectal excision with free surgical margins. There were lymph nodes metastases but no distant metastases at the time of diagnosis. The patient refused to receive adjuvant chemotherapy and died 6 months later due to liver failure as a result of multiple hepatic metastases. DISCUSSION: There are not known predisposing factors for the development of neuroendocrine rectal carcinoma. A neuroendocrine carcinoma of the rectum is a rare tumor with an incidence of less than 0.1% of all colorectal malignancies. The median survival ranges from 5 to 10.4 months in several studies and there are not sufficient data in bibliography about ideal adjuvant therapy after resection of mixed squamous large cell neuroendocrine carcinoma of the rectum. CONCLUSION: Low anterior resection and total mesorectal excision with free surgical margins in the presence of lymph nodes metastasis is not a sufficient treatment for rectal neuroendocrine carcinoma. More studies should be done in order to determine the ideal adjuvant treatment of these rare and aggressive tumors.

Primary midgut volvulus in adults: report of two cases and review of the literature.

INTRODUCTION: This is a report of two male patients (35 and 54 years old, respectively) admitted to our surgical department with signs of small-bowel obstruction. CASE PRESENTATIONS: Diagnostic workup with plain abdominal radiographs and, more specifically, computed tomography suggested the possibility of bowel rotation. In order to exclude any possibility of associated intestinal ischemia, both patients underwent exploratory laparotomy, which revealed a midgut volvulus without any associated obvious cause or pathology. DISCUSSION: Both patients had an eventful outcome. Epidemiologic characteristics, clinical presentation, diagnostic workup, surgical treatment, and morbidity-mortality rates of small-bowel volvulus have been reviewed and thoroughly discussed.

Lifestyle intervention favorably affects weight loss and maintenance following obesity surgery.

The present study was designed to evaluate the 3 year effects of a lifestyle intervention on weight loss and maintenance, dietary, and physical activity habits and eating behavior of patients following vertical banded gastroplasty (VBG). Thirty severely obese female volunteers were included in the study and they were randomly assigned to one of two intervention groups: usual care (UC) or lifestyle intervention (LS) group. Patients were followed for 3 years postoperatively. Outcome measures included weight loss, dietary habits, physical activity level (PAL), and eating behavior changes. Weight was significantly lower in the LS group after 12 months (84.4 +/- 3.9 kg vs. 98.4 +/- 4.4 kg, P < 0.05), 24 months (83.0 +/- 3.3 vs. 101.9 +/- 5.3 kg, P < 0.05), and 36 months following surgery (84.2 +/- 3.3 vs. 102.5 +/- 3.5 kg, P < 0.05). Repeated measures ANOVA revealed significant differences between the two groups overall and at specific time points for the PAL and TV viewing. With regard to eating behavior, the LS group scored significantly better in total Dutch Eating Behavior Questionnaire (DEBQ), Restraint Eating and External Eating scales at all postoperative time points. Similarly, significant differences were found between the two groups in dietary intake. These findings outline the importance of lifestyle intervention on weight loss and maintenance following bariatric surgery. The favorable effects of lifestyle intervention may be through adoption of healthier eating behaviors and increased physical activity.

Changes in liver histology accompanying massive weight loss after gastroplasty for morbid obesity.

BACKGROUND: Nonalcoholic steatohepatitis (NASH) is common in morbid obesity. Our goal was to evaluate the alterations in liver histology and biochemistry before and after weight loss in 51 morbidly obese patients following Mason's vertical banded gastroplasty. METHODS: Two biopsies were performed (on entry and after an average of 18 months), while 16 of these subjects had a third biopsy 17 months after the second. RESULTS: On entry, steatosis and steatohepatitis (mostly grade 3) were present in 98.0% and fibrosis (mostly stage 2) in 94.1% of the subjects. After an excess weight loss of 66%, steatosis and steatohepatitis improved significantly (P<0.001). Although a significant overall decrease in fibrosis occurred (P=0.002), 21 patients (41.1%) did not change and only 6 patients (11.7%) increased in fibrosis. None developed cirrhosis. The decrease in steatohepatitis was significantly correlated (P=0.011) with the reduction of BMI. Fasting serum glucose, lipids, lipoproteins, transaminases, gamma-glutamyl transpeptidase, alkaline phosphatase and fibrinogen were also significantly improved at the time of the second biopsy. The third biopsy performed in 16 of the subjects showed further significant improvement in liver histology. CONCLUSION: NASH improved significantly with massive weight loss in non-diabetic, non-alcoholic, morbidly obese subjects, while fibrosis improved in nearly half of the patients.

Gastric cancer occurring after vertical banded gastroplasty.

A case of gastric cancer after vertical banded gastroplasty (VBG) is presented. A 44-year-old man presented with vomiting and weight loss 6 years after VBG. Endoscopy revealed a poorly differentiated gastric adenocarcinoma. The patient underwent a Whipple pancreaticoduodenectomy and received chemotherapy. He expired 6 months later. From our case and review of the literature, development of gastric cancer after VBG is very rare. The authors suggest that patients undergoing VBG be monitored by endoscopy after the operation.