Days of symptoms and days of hospital admission before surgery do not influence the results of cholecystectomy in moderate acute calculous cholecystitis-Cholecystectomy remains the best treatment.

BACKGROUND AND AIMS: early cholecystectomy is the gold-standard treatment for acute calculous cholecystitis (ACC), although many surgeons still prefer delayed cholecystectomy for grade II to avoid surgical complications. The aim of this study was to analyze the postoperative morbidity and mortality of Tokyo Guidelines grade-II ACC as treated with cholecystectomy, taking into account the days of symptoms and days since hospital admission. MATERIALS AND METHODS: a unicenter, retrospective study was performed based on a prospective database. Patients with grade-II ACC treated with cholecystectomy were selected. Patients were analyzed according to days of symptoms (DS) and days of hospital admission (DHA) until cholecystectomy. Patients were subdivided into 3 groups: < 3 days, 3-5 days, and > 5 days. Univariate and multivariate analyses were performed for morbidity and mortality. Categorical variables were compared using the Chi-squared or Fischer's exact test. Continuous variables were compared using the Mann-Whitney U-test. The level of statistical significance was set at p < 0.05. RESULTS: a total of 998 patients with ACC diagnosis were included; 567 with grade-II ACC and 368 treated with cholecystectomy. Nearly 90 % were treated laparoscopically and 48.1 % underwent surgery the same day of emergency admission. With regard to DS and DHA, there were no statistical differences for severe postoperative complications, although a greater number of complications were detected in the > 5 DS group (p: 0.32) and > 5 DHA group (p: 0.00). Statistically significant differences were found in DS for mortality (p: 0.04). Postoperative length of stay was longer for > 5 DHA group cholecystectomies (p > 0.05). There were no differences with regard to hospital readmission. CONCLUSION: with regard to DS or DHA until cholecystectomy, there were no statistically significant differences related to severe postoperative complications, length of stay, or mortality.

Bariatric surgery decreases oxidative stress and protein glycosylation in patients with morbid obesity.

BACKGROUND: There is growing evidence that oxidative stress (OS) is a critical factor linking obesity with its associated comorbidities, such as cardiovascular diseases. AIM: To evaluate the degree of OS in people with morbid obesity and its relationship with glycoproteins, determined using 1H-NMR spectroscopy, before and after bariatric surgery (BS). METHODS: In this observational cohort study, plasma from 24 patients with BMI ≥ 40 kg/m2 (age: 21-65 years) was used to measure metabolites implicated in OS. We measured glycoprotein (GlycA, GlycB and GlycF) areas and shape factors (H/W = height/width). RESULTS: One year after BS, oxidized low-density lipoprotein had decreased by 49% (P < .0001), malondialdehyde by 32% (P = .0019) and lipoprotein (a) by 21% (P = .0039). The antioxidant enzymes paraoxonase-1 and catalase increased after BS (43%, P < .0001 and 54%, P = .0002, respectively). Superoxide dismutase-2 had fallen 1 year after BS (32%, P = .0052). After BS, both the glycoprotein areas and shape factors decreased by 20%-26%. These glycoproteins were significantly correlated with OS parameters. The plasma atherogenic index was 63% higher in obese individuals than 1 year after BS and correlated positively with glycoproteins. CONCLUSION: For the first time, we here demonstrate the relationship between OS parameters and glycoproteins in people with morbid obesity. So glycoproteins could therefore be a good indicator, together with the oxidative state to assess patient prognosis after BS.

Failure to perform index cholecystectomy during acute cholecystitis results in significant morbidity for patients who present with recurrence.

BACKGROUND: Although index cholecystectomy is considered the treatment of choice for acute cholecystitis (AC), many hospital systems struggle to provide such a service. The aim of this study was to analyze the effect of failure to perform index cholecystectomy in patients presenting with acute cholecystitis. METHODS: Between June 2010 and December 2015, all patients presenting to one hospital with an initial attack of AC were enrolled into a prospective database. Patient's records were reviewed up until point of delayed cholecystectomy or for a minimum of 24 months after the initial presentation with AC. Recurrent AC was defined as early (<6 weeks from initial discharge) or late (>6 weeks from initial discharge). RESULTS: In total 998 patients presented with AC, 409 (41%) of whom were discharged without index cholecystectomy. Eighty-three (20%) patients presented with AC recurrence (ACR). Compared to the first AC episode, patients were more likely to present with grade III AC and suffer significantly greater morbidity (p < 0.05 for all comparisons). A prior history of biliary disease was associated with ACR (p = 0.002). ACR occurred early in 48 (58%) patients and delayed in 35 (42%) patients. CONCLUSIONS: Twenty percent of patients discharged without cholecystectomy after their first attack of ACR will develop recurrence within the first two years. Half of ACR will occur within 6 weeks. Patients who present with ACR are more likely to develop more severe AC and are likely to suffer greater morbidity as compared to their first attack.

Litiasic acute cholecystitis: application of Tokyo Guidelines in severity grading.

BACKGROUND: Acute calculous cholecystitis (AC) is one of the most frequent surgical emergencies in our field. Laparoscopic cholecystectomy is considered the treatment of choice, although not sufficiently widespread. OBJECTIVE: To analyze the application of the Tokyo Guidelines in the management of AC and to determine the influence of the degree of severity on management and prognosis. METHOD: Prospective, observational study of patients with a primary diagnosis of AC between 2010 and 2015.. Exclusion criteria: AC recurrence; AC as a secondary diagnosis; acalculous cholecystitis; concurrent biliary pathology. Severity was classified according Tokyo 2013 Guidelines. RESULTS: 998 patients were included: 338 (33.9%) mild AC, 567 (56.8%) moderate AC, and 93 (9.3%) severe AC. A total of 582 (58.3%) patients were operated on. Postoperative complications Dindo-Clavien grade ≥ II 12.6%: mild AC 3.6%; moderate AC 12.2%; severe AC 49.0% (p < 0.001). Overall mortality 2%: mild AC 0%; moderate AC 0.5%; severe AC 18.0% (p < 0.001). CONCLUSION: Urgent laparoscopic cholecystectomy remains the treatment of choice for mild and moderate AC. In patients with severe AC, the risks and benefits of surgery should be assessed, given the high degree of complications and associated mortality.

ANTECEDENTES: La colecistitis aguda litiásica (CA) es una de las urgencias quirúrgicas más frecuentes en nuestro medio. La colecistectomía laparoscópica se considera el tratamiento de elección, aunque sigue sin ser una realidad su práctica generalizada. OBJETIVO: Analizar la aplicación de las Guías de Tokio en el manejo de la CA y determinar la influencia de la gravedad en el manejo y el pronóstico. MÉTODO: Estudio prospectivo, observacional, de pacientes con diagnóstico primario de CA entre 2010 y 2015. Criterios de exclusión: recidiva de CA, CA como diagnóstico secundario, CA alitiásica u otra patología biliar concomitante. Se ha clasificado la gravedad según las Guías de Tokio de 2013. RESULTADOS: Se incluyen 998 CA: 338 (33.9%) leves, 567 (56.8%) moderadas y 93 (9.3%) graves. Se operaron 582 pacientes (58.3%), y posteriormente 15 precisaron rescate. Complicaciones posoperatorias Dindo-Clavien ≥ 12,6%: CA leve 3,6%, CA moderada 12,2%, CA grave 49% (p < 0.001). Mortalidad global 2%: CA leve 0%, CA moderada 0.5%, CA grave 18% (p < 0.001). CONCLUSIÓN: La colecistectomía laparoscópica sigue siendo el tratamiento de elección para la CA leve y moderada. En pacientes con CA grave debe valorarse el riesgo-beneficio de la cirugía, dadas las complicaciones y la mortalidad asociadas.

Effect of bariatric surgery on inflammation and endothelial dysfunction as processes underlying subclinical atherosclerosis in morbid obesity.

BACKGROUND: Inflammation and endothelial dysfunction are associated with morbid obesity (MO) and atherosclerosis. OBJECTIVE: To evaluate inflammation and endothelial function as the initial mechanisms underlying subclinical atherosclerosis in patients with MO, with and without atheromas, and their evolution after bariatric surgery (BS). SETTING: Arnau de Vilanova University Hospital and University of Barcelona. METHODS: Plasma samples from 66 patients with MO were obtained before BS and 6 and 12 months after BS. Patients were divided into 2 groups based on the presence of atheromatous plaques (detected by ultrasound imaging). RESULTS: Inflammation was increased as demonstrated by changes in the levels of fibroblast growth factor 21, adiponectin, leptin, interleukin 6, tumor growth factor α, nonesterified free fatty acids, lipoprotein(a) and C-reactive protein (CRP). Endothelial dysfunction was characterized by impaired angiogenesis (measured through angiopoietin 1 and 2 and brain-derived neurotrophic factor), vascular function (changes in endothelin 1 and thrombomodulin levels), and diapedesis (changes in intercellular and vascular cell adhesion molecules, and E- and P-selectins). Both mechanisms occurred regardless of the presence of atheromas. BS ameliorated both processes even in patients who already had subclinical atherosclerosis. However, CRP, thrombomodulin, and P-selectin levels were higher in patients with atheromas. CONCLUSIONS: Endothelial dysfunction and inflammation were detected before the appearance of structural changes in vessel walls on ultrasonography images. BS might prevent or slow atherogenesis in the early stages by breaking the vicious circle between inflammation and endothelial dysfunction. CRP, thrombomodulin, and P-selectin may have a critical role in plaque development and, together with the study of endothelial dysfunction, might be useful in assessing early atherosclerosis and its evolution after BS.

Effect of bariatric surgery in the evolution of oxidative stress depending on the presence of atheroma in patients with morbid obesity.

BACKGROUND: Morbid obesity is associated with accelerated atherosclerosis, a chronic vascular disease related to oxidative stress (OS) and endothelial dysfunction. OBJECTIVES: We aimed to evaluate the effect of bariatric surgery (BS) on oxidative stress as a cardiovascular risk factor in patients with and without atheromatous plaques. SETTING: Arnau de Vilanova University Hospital and University of Barcelona. METHODS: Plasma samples from 66 patients with morbid obesity were obtained before BS and 6 and 12 months after. Patients were divided into 2 groups based on the presence of atheromatous plaques (detected by ultrasonography). OS parameters were measured by enzyme-linked immunosorbent assay. RESULTS: Patients with morbid obesity had OS independently of the presence of an atheroma, but oxidized low-density lipoprotein levels were higher in patients with plaques throughout the study (P = .0430). After surgery, oxidized low-density lipoprotein and malondialdehyde levels decreased significantly (P < .0001 in both cases). At the beginning of the study, antioxidant enzyme levels were the same between the groups. After surgery, paraoxonase 1 levels were increased (P < .0001) in the group without plaque, being significantly higher (P = .0147). Superoxide dismutase 2 levels were only decreased in patients without plaque (P < .0010), while catalase activity was higher in patients with plaque. CONCLUSIONS: Morbid obesity may lead to chronic OS, which increases predisposition to atherogenesis. BS improves the antioxidant profile and reduces OS and co-morbidities in both groups. However, the benefits are greater for patients without plaque. Therefore, BS may prevent atheroma formation and also could prevent plaque rupture by decreasing OS.

Impact of bariatric surgery on subclinical atherosclerosis in patients with morbid obesity.

BACKGROUND: The main cause of death in obese individuals is cardiovascular disease precipitated by atherosclerosis. Endothelial dysfunction and inflammation are considered early events in the development of the disease. OBJECTIVES: The aim of this study was to identify biomarkers of subclinical atherosclerosis in patients with morbid obesity by comparing clinical, vascular, and biochemical parameters indicative of endothelial dysfunction in patients with and without atheromatous plaque and monitoring changes after bariatric surgery. SETTINGS: Multicenter collaboration between Biochemistry and Biomedicine Department in Barcelona University and University Hospital Arnau de Vilanova in Lleida. METHODS: Plasma samples from 66 patients with morbid obesity were obtained before bariatric surgery and at 6 and 12 months after. Patients were divided into 2 groups based on the presence of atheromatous plaque. We used contrast-enhanced carotid ultrasound, enzyme-linked immunosorbent assay, Griess, and EndoPAT-2000 methods. RESULTS: Patients with plaque showed the worst profile of cardiovascular risk factors. Carotid intima-media thickness and plasminogen activator inhibitor-1 were higher in plaque group (P < .0001). After bariatric surgery, vasa vasorum, oxidized low-density lipoprotein, and plasminogen activator inhibitor-1 decreased (P < .0001 in all cases). CONCLUSIONS: Obesity promotes atherogenesis, leading to vascular endothelial damage. Bariatric surgery reduces cardiovascular risk and the prognosis is better for patients without plaque. The increase in plasminogen activator inhibitor-1, carotid intima-media thickness, and vasa vasorum proliferation might be the first alterations in the atheromatous process in obesity and could serve as good biomarkers of subclinical atherosclerosis.

Acute Cholecystitis in Very Elderly Patients: Disease Management, Outcomes, and Risk Factors for Complications.

BACKGROUND: The aim of this study was to evaluate the characteristics, management, and outcomes of acute cholecystitis in patients ≥80 years. METHODS: This was a retrospective analysis of data from a prospective single-center patient registry. RESULTS: The study population was composed of 348 patients, which were divided into two groups: those younger (Group A) and those older (Group B) than the median age (85.4 years). Although demographic and clinical characteristics of the two groups were similar, the disease management was clearly different, with older patients undergoing cholecystectomy less frequently (n=80 46.0% in Group A vs n=39 22.4% in Group B; p < 0.001). The outcomes in both groups of age were similar, with 30-day mortality of 3.7%, morbidity of 17.2%, and readmissions of 4.2% and two-year AC recurrence in nonoperated patients of 22.5%. No differences were seen between operated and no operated patients. Severe (Grade III) AC was the only independent factor significantly associated with mortality (OR 86.05 (95% CI: 11-679); p < 0.001). CONCLUSIONS: In elderly patients with AC, the choice of therapeutic options was not limited by the age per se, but rather by the disease severity (grade III AC) and/or poor physical status (ASA III-IV). In case of grade I-II AC, laparoscopic cholecystectomy can be safely performed and yield good results even in very old patients. Patients with grade III AC present high risk of morbidity and mortality, and the treatment should be individualized. ASA IV patients should avoid cholecystectomy, being antibiotic treatment and cholecystectomy the best option.

Seasonal variation of body weight loss after bariatric surgery.

Seasonal variations have been described in humans in several variables such as sleep, mood, appetite, food preferences, or body weight. We hypothesized that these variations could also influence the decrease in body weight rate in patients submitted to body weight loss interventions. Thus, here we tested the variations of weight loss according to the time of the year the surgery took place in a group patients (n = 1322) submitted to bariatric surgery in the Hospital Universitari de la Vall d'Hebron in Barcelona (geographical coordinates: 41°25'41″N 2°8'32″E). For the analysis, the percentage of total body weight loss (%TWL), excess body weight loss (%EWL) and percentage of body mass index loss (%BMIL) were calculated at 3 (n = 1255), 6 (n = 1172), 9 (n = 1002), and 12 months (n = 1076) after surgery. For %EWL and %BMIL a statistically significant seasonal variation was detected when the variables were calculated at 3 months, but not at the other times, with more weight loss in summer-fall. However, seasonal variations were not detected for %TWL (p = 0.09). The mean amplitude of the seasonal rhythm for %EWL was of 1.8%, while for the rhythm of %BMIL was 0.7%. Moreover, a second peak was detected in January-February modulating the seasonal rhythm of the two variables. Results confirm seasonal variations in humans and indicate that short term responses to weight loss can be modulated by the time of year.

Seasonal variations of changes in lipid and glucidic variables after bariatric surgery.

Seasonality is a phenomenon that is characterized by changes over the year in sleep, mood, behaviour, appetite and body weight. In humans, seasonal variations have been found in certain variables, such as lipid variables and body mass index. We hypothesize that this rhythm could influence the expected variation of the levels of biochemical variables in cases of body weight loss. Thus, the goal of this study was to observe whether the time of year in which bariatric surgery (BS) took place modulated the changes in several variables related to glucidic and lipid metabolism. Blood samples were obtained from 24 women and 10 men before BS and 1 and 3 months after BS. We calculated the percentage of variation that occurred for each individual and for each variable as a function of the time of the year. Data were adjusted to a 12-month period sinusoidal curve, with significance being set at p < 0.05. The results showed that almost all of the studied variables changed due to the BS according to a seasonal rhythm. Most of the variables showed a decrease that was most prominent in winter. In the cases of body mass index (BMI), adrenocorticotropin hormone (ACTH), and cortisol, the highest variation occurred in winter. Insulin and cholesterol in high-density lipoproteins (cHLD) variations were higher in springtime. Glucose variation showed a decrease after surgery with acrophase in summer-fall and plasminogen activator inhibitor-1 (PAI-1) and homeostatic model assessment-insulin resistance (HOMA-IR) in spring-summer. Ghrelin levels showed increases with a rhythm of variation with an acrophase in summer-fall. The seasonal rhythm found in this study fits nearly with the inverse of the endogenous circannual rhythm of the variables studied. The time of the year when the highest variation takes place is related to the circannual rhythm of the variable. The results agree with the manifestation of seasonal rhythm in human biochemical variables, which are reflected in the responses to weight loss after BS.