The impact of laparoscopic sleeve gastrectomy on weight loss and obesity-associated comorbidities: the results of 3 years of follow-up.

BACKGROUND: Laparoscopic sleeve gastrectomy is one of the most recent advances in the surgical treatment of morbid obesity. Extended follow-up studies of large cohorts are needed to establish the usefulness of the operation. The objectives of this study are to delineate the role of sleeve gastrectomy in weight loss and in comorbidities among obese patients. METHODS: Patients who underwent laparoscopic sleeve gastrectomy in a single bariatric center were followed up for a 3-year period. Weight loss and status of several comorbidities were assessed at the 1st, 3rd, 6th, 12th, 18th, 24(th), and 36th postoperative month. RESULTS: Overall, after 3 years of follow-up of 88 patients, the mean body mass index (BMI) of the patients was 29.8 kg/m(2) (SD ±6.1), the % total weight loss was 38.1% (SD ±12.9), the % excess weight loss was 69.5% (SD ±17.5), and the % estimated BMI loss was 81.4% (SD ±22.3). These parameters changed significantly over the first year of follow-up (p < 0.001) and subsequently stabilized. The percentages of patients with hypertension (33.3%), hyperlipidemia (26.4%), diabetes mellitus (20.7%), obstructive sleep apnea (20.2%), and gastroesophageal reflux disease (GERD-27%) were significantly reduced (10.5, 9.2, 1.1, 1.1, and 9.2% respectively at 36 months postoperation), while 10 new cases of GERD appeared postoperatively. However, only three of the new GERD cases required medication, and only one of them experienced symptoms that persisted after the 3-year period. CONCLUSION: Three years of close follow-up of patients who had undergone laparoscopic sleeve gastrectomy demonstrated satisfactory weight loss results. Promising results were also obtained regarding various comorbidities of obese patients. Longer follow-up studies for more patients are needed to delineate the exact role of sleeve gastrectomy on postoperative outcomes.

Prospective evaluation of health-related quality of life in a homogeneous Mediterranean group of colorectal cancer patients.

This study was designed to prospectively evaluate health-related quality of life in a homogeneous Mediterranean group of colorectal cancer patients. Ninety-five colorectal cancer patients were preoperatively assessed and followed-up with by skilled investigators using the Short Form-36 Health Survey questionnaire. Overall, patients showed deterioration in all domains, except for pain, when baseline values were compared with 3 and 6 months postoperatively (P = 0.0001). A significant improvement of all Short Form-36 Health Survey questionnaire domains was noted between 6 and 12 months (P = 0.0001). Scores for general health, pain, emotional well-being, and role limitations due to emotional problems at 1 year were shown better than preoperative (P < 0.001). Improved scores in role limitations due to physical health and emotional problems were found at baseline and at 1 year, when laparoscopic were compared with open resections (P < 0.05). Patients that received chemotherapy proved to be more vulnerable regarding their energy, social functioning, and role limitations at 3 months (P < 0.05), whereas older patients had diminished physical functioning at 3 and 6 and 12 months (P < 0.05) postoperatively. Greek colorectal cancer patients remain fragile up to 6 months after surgery, with significant improvements at 1 year, whereas certain aspects of health-related quality of life at 1 year may be even better than before surgery.

P53 and EGFR expression in colorectal cancer: a reappraisal of 'old' tissue markers in patients with long follow-up.

BACKGROUND: Extensive research into the biology of colorectal cancer has identified a plethora of molecular markers reputed to provide prognostic information. During the last two decades conflicting results have been drawn on the role of the p53 tumour suppressor gene and of the first identified member of the type receptor tyrosine kinase family, EGFR, on colorectal cancer prognosis, p53 Mutational status has been associated with both improved and reduced survival. EGFR has been associated with reduced length of survival, increasing Dukes' stage and lymph node metastases in several reports, but as many studies have reported no association with unfavourable prognostic parameters. The aim of this study was to evaluate the p53 and EGFR expression in patients with an at least 5-year follow-up. PATIENTS AND METHODS: Paraffin-embedded material was retrospectively collected from 164 colorectal adenocarcinoma (50 rectal) patients, who had been operated on between 1994 and 2003. The median follow-up was 5 years (range: 1-14). p53 and EGFR expression were evaluated by immunohistochemistry. RESULTS: Positive p53 immunostaining and EGFR expression was observed in 63.4% and 43.9% of patients, respectively. p53 and EGFR positivity rates were significantly interrelated (p = 0.004). No significant correlation was found with the examined clinicopathological parameters except for advanced T-stage, which demonstrated significant associations with p53 expression (p = 0.004), EGFR expression (p = 0.0001) and p53/EGFR coexpression (p = 0.001). In univariate survival analysis (log rank test), stage (p = 0.0001), lymphovascular invasion (p = 0.005) and perineural infiltration (p = 0.004) were associated with the overall cancer-specific survival, while a trend existed for EGFR (p = 0.06) and p53/EGFR coexpression (p = 0.07). On multivariate analysis, only stage was associated with increased risk of cancer death (Cox regression analysis p = 0.0001, b-coefficient (SE): 1.898 (0.383). CONCLUSION: p53 and EGFR were overexpressed in this colorectal cancer patient population and were significantly associated with advanced T stage. In the context of new therapeutic strategies using EGFR-targeted therapies, although EGFR remains a controversial prognostic factor, this expression-stage association may play a crucial role in a decision to initiate an adjuvant treatment.

Prospective evaluation of sexual function after open and laparoscopic surgery for rectal cancer.

BACKGROUND: Sexual function may be harmed after treatment for rectal cancer. This study aimed to evaluate prospectively the incidence of sexual dysfunction after rectal cancer treatment and to compare the effects of laparoscopic and traditional open approaches in terms of postoperative sexual function. METHODS: Baseline and 3-, 6-, and 12-month assessments of sexual dysfunction using the International Index of Erectile Function (IIEF) and its specific domains prospectively took place for 56 patients who underwent rectal cancer surgery (38 open vs. 18 laparoscopic procedures, 38 low anterior vs. 18 abdominoperineal resections). The preliminary results are presented. RESULTS: The average total IIEF and isolated IIEF response domain scores were significantly decreased after surgery (p < 0.01) except for the intercourse satisfaction and overall satisfaction scores at 12 months. An improvement in IIEF scores was observed between the 3- and 6-month assessment points (p < 0.01) except for the erectile function and orgasmic function scores. No significant differences were observed between the open and laparoscopic groups in the total IIEF and domain scores preoperatively and at the 3- and 6-month assessment points. The rates of sexual dysfunction did not differ significantly preoperatively or at 3 months postoperatively when open and laparoscopic procedures were compared, although there was a trend in favor of laparoscopic surgery at 6 months (p = 0.076). The baseline IIEF score and the baseline, 3-, and 6-month sexual desire scores were better (p = 0.035, 0.004, 0.017, and 0.061, respectively) in the low anterior resection group than in the abdominoperineal resection group. CONCLUSIONS: Rectal cancer resections were postoperatively associated with a significant reduction in IIEF scores and high rates of sexual dysfunction at 3 and 6 months. The IIEF and domain scores at different assessment points were comparable between the laparoscopic and open surgery groups. Extending the monitoring period and adding more patients in this ongoing prospective study will further elucidate postoperative sexual dysfunction after rectal cancer surgery.

Gastritis might be considered as a technical factor affecting laparoscopic sleeve gastrectomy.

There is a paucity of data regarding gastritis as a technical factor affecting the surgical technique. Antritis and gastritis usually cause stomach wall thickness which can interrupt stapler function or even can cause serosal tear during the dissection. We report a video presentation of laparoscopic sleeve gastrectomy in a morbidly obese patient with antritis. Choosing black cartridge for patients with Helicobacter pylori gastritis might be the optimal technique for division of the antrum in laparoscopic sleeve gastrectomy. Further studies are required to clarify this parameter.

Impact of Laparoscopic Sleeve Gastrectomy on Weight Loss and Associated Comorbidities in Adolescents and Young Adults.

BACKGROUND: Obesity is a common disease affecting young adults and adolescents worldwide. This study aims to delineate the role of laparoscopic sleeve gastrectomy (LSG) in weight loss and associated comorbidities to adolescents and young adults. PATIENTS AND METHODS: This study is a retrospective analysis of a prospective cohort of all young adults 16-22 years old who underwent LSG for morbid obesity and were followed up for 24 months. Demographic data, weight loss, and the status of several comorbidities, such as diabetes mellitus, hypertension, and dyslipidemia, were assessed at postoperative Months 1, 3, 6, 12, 18, and 24. RESULTS: Overall, at baseline and after 24 months of close follow-up of 37 adolescents and young adults who had undergone LSG, the body mass index of the patients was 46.93 ± 6.07 kg/m(2) versus 26.2 ± 3.6 kg/m(2) (P < .001), and the body weight was 143 ± 29 kg versus 78 ± 15 kg (P < .001). From the first follow-up visit after operation to the last one at the 24 months, there was also a significant difference in percentage excess weight loss (22.40 ± 6.58% versus 81 ± 17%; P < .001), body mass index difference (-5.47 ± 1.69 kg/m(2) versus -18.08 ± 4.38 kg/m(2); P < .001), and percentage excess body mass index loss (26.06 ± 7.56% versus 96 ± 21%; P < .001). The percentage of the adolescents and young adults with diabetes mellitus, hypertension, and dyslipidemia were diminished gradually at 6 months postoperatively (P < .001). CONCLUSIONS: LSG represents a safe and attractive treatment strategy for morbidly obese adolescents and young adults with comorbidities. In this study group excellent resolution of excess weight and comorbid conditions is achieved 2 years after LSG.

Staple Line Reinforcement with Stitch in Laparoscopic Sleeve Gastrectomies. Is It Useful or Harmful?

BACKGROUND: Reinforcement of the staple line in laparoscopic sleeve gastrectomy (LSG) is a practice that leads to less morbidity, but equivocal results have been reported in the literature. MATERIALS AND METHODS: This is a prospective randomized study comparing two groups of patients who underwent LSG. In one group LSG was performed with a running absorbable suture placement at the staple line. In the other group the running suture was not placed. General data of the patients, as well as intraoperative and postoperative data, were gathered and statistically analyzed. RESULTS: Overall, 146 patients were subjected to LSG. In 84 patients a running suture was placed, and in 62 patients no suture was placed. No significant differences were found between the two groups in demographic data. No significant differences were found also in the intraoperative data, such as number of trocars, number and type of cartridges, drain placement, and operative time (45±21 versus 40±20 minutes, respectively; P<.05). Intraoperative complications were significantly more in the group with the suture placement (33.3% versus 16.1%, respectively; P<.05). Hematomas developed intraoperatively in more patients after the placement of the running suture (9.5% versus 0.0%, respectively; P<.05). Postoperatively, there was no significant difference in morbidity between the two groups (8.3% versus 9.7%, respectively; P>.05). CONCLUSIONS: After this randomized study, final conclusions about the efficacy of this running suture to the staple line cannot be made. To the contrary, problems seem to exist after such reinforcement of the staple line, such as hematomas. Dealing with possible leaks and hemorrhage of the staple line is also problematic after placement of the running suture.

GERD-Related Questionnaires and Obese Population: Can They Really Reflect the Severity of the Disease and the Impact of GERD on Quality of Patients' Life?

INTRODUCTION: There is a strong association between obesity and gastroesophageal reflux disease (GERD). GERD-related questionnaires have been developed in order to objectify symptoms. However, none of them has been tested in obese population. PURPOSE: The purpose of this study is to evaluate if GERD score and GERD-Health-Related Quality of Life (HRQL) can reflect severity of the disease and screen obese patients for GERD preoperatively. GERD's impact on the quality of life of obese patients is being assessed with the use of EORTC-QLQ C30. PATIENTS-METHODS: Obese patients during their preoperative evaluation were recruited regardless of the presence of GERD symptoms. A targeted GERD symptom history was obtained. Patients completed GERD score, GERD-HRQL, and EORTC-QLQ C30, and then, a 24-h multichannel intraluminal impedance pHmetry (MIIpH) was conducted. RESULTS: Forty-seven consecutive obese patients with mean age 39.91 years and mean BMI 46.94 kg/m(2) were included in the study. GERD score and GERD-HRQL have a positive linear correlation with DeMeester score (p = 0.001 and p < 0.001, respectively). EORTC QLQ-C30 does not correlate with DeMeester score. CONCLUSIONS: GERD-related questionnaires could be used in obese population as preoperative screening tool for GERD. However, our results indicate that the quality of life of obese patients is not affected by the existence of GERD.

Using Ligasure™ or Harmonic Ace® in Laparoscopic Sleeve Gastrectomies? A Prospective Randomized Study.

BACKGROUND: Laparoscopic sleeve gastrectomy is one of the most recent advances of surgery for treating morbid obesity. Many laparoscopic devices have evolved to provide vascular control and tissue dissection. METHODS: This is a prospective randomized study comparing the intraoperative and postoperative complications and operative time of two groups of patients who underwent laparoscopic sleeve gastrectomy. In the first group after randomization, sleeve gastrectomy was performed using Ligasure™ and in the second group Harmonic Ace® was used. RESULTS: In total, 94 patients were enrolled in the study allocated in two groups. In group 1, 43 patients were operated using Ligasure™, and in group 2, 51 patients were operated using Harmonic Ace®. No significant differences were highlighted between these two groups with regards to operative time (45.0 ± 15.0 vs 40.0 ± 20.0 min, p = 0.199), intraoperative complications (32.6 vs 15.7 %, p = 0.054) and postoperative complications (4.7 vs 17.6 %, p = 0.051). CONCLUSIONS: Both Ligasure™ and Harmonic Ace® provide surgeons ergonomy, and no significant differences were shown in operative time and complications. Safety and efficacy in such demanding operations is of critical importance. Choice between these two shears lies with surgeon's preference.

The use of serum uric acid concentration as an indicator of laparoscopic sleeve gastrectomy success.

Laparoscopic sleeve gastrectomy (LSG) effectively reduces weight by restricting gastric capacity and altering gut hormones levels. We designed a prospective study to investigate the correlation of serum uric acid (SUA) concentration and weight loss. SUA and body mass index (BMI) were measured preoperatively and on first postoperative month and year in patients who underwent LSG in our department of bariatric surgery. Data on 55 patients were analyzed. Preoperative SUA concentration had a significant positive correlation with percentage of total weight loss (TWL) on first postoperative month (P = 0.001) and year (P = 0.002). SUA concentration on first postoperative month had a positive correlation with percentage of TWL on first postoperative year (P = 0.004). SUA concentration could be used as a predictor of LSG's success and could help in early detection of patients with rapid loss of weight, in order to prevent complications.

BRCA2 gene mutations in Greek patients with familial breast cancer.

Family history is a well-recognized risk factor for the development of breast cancer. The isolation of BRCA1 and BRCA2 genes, the two major predisposing genes in familial and to early onset breast and ovarian cancer, has resulted to the identification of a large number of families with mutations in these two genes. Despite the large number of distinct mutations detected in both genes, several mutations have been found to recur in unrelated families of diverse geographical origin. We have analyzed 27 Greek patients with familial breast cancer the majority of those having one first and one second degree relatives affected and 28 patients with sporadic breast cancer for BRCA2 germline mutations. The techniques used were single-strand conformation polymorphism analysis (SSCP) followed by sequencing. Furthermore, the clinical presentation and prognosis of BRCA2 associated breast cancer cases was compared to 20 adequately matched for age and date of diagnosis (within one year) sporadic breast cancer patients. We identified three novel BRCA2 mutations (3058delA, 6024delTA, and 4147delG) in the ovarian cancer cluster region (OCCR) and one already known (2024del5) germline BRCA2 gene mutation in five different breast cancer families. The 4147delG mutation was detected in two unrelated patients. BRCA2 germline mutations were correlated with early-onset breast cancer RR=4.77 (95% CI: 0.666-34.463). Although patients with BRCA2 germline mutations did not have a distinct histological phenotype they had an improved overall survival (100% vs 65%). Our findings suggest that there is a cluster of novel mutations in exons 10 and 11 in Greek patients with familial breast cancer. These mutations appear to have a milder clinical phenotype when compared to the rest of the study group.

Laparoscopic excision of a lymphangioma of the cystic duct.

Lymphangiomas are benign tumors that originate from malformations of the lymphatic vessels. They are rarely seen in adults and are extremely rare in the cystic duct. Herein, we report the case of a 48-year-old woman who presented with a cystic lymphangioma that originated in the cystic duct and was excised laparoscopically. Preoperative imaging revealed the cystic and benign nature of the lesion. Laparoscopic abdominal exploration and excision of the 10-cm cystic lymphangioma were performed. Four trocar sites were used, and the excision was achieved using clips and electrocautery. The laparoscopic excision of these benign masses is safe and efficacious in experienced hands. This procedure requires preoperative planning and must be individualized.