Laparoscopic subtotal gastrectomy for the treatment of advanced gastric cancer: a comparison with open procedure at the beginning of the learning curve.

BACKGROUND: In the last decades, after some initial concern, laparoscopic subtotal gastrectomy (LSG) is gaining popularity also for the treatment of advanced gastric cancer (AGC). The aim of this study is to compare a single surgeon initial experience on LSG and open subtotal gastrectomy in terms of surgical safety and radicality, postoperative recovery and midterm oncological outcomes. METHODS: a case control study was conducted matching the first 13 LSG for AGC with 13 open procedures performed by the same surgeon. Operative and pathological data, postoperative parameters and midterm oncological outcomes were analyzed. RESULTS: There was no significant difference in mortality (0%) and morbidity, while the laparoscopic approach allowed lower analgesic consumption and faster bowel movement recovery. Operation time was significantly higher in LSG patients (301.5 vs 232 min, p: 0.023), with an evident learning curve effect. Both groups had a high rate of adequate lymph node harvest, but the number was significantly higher in LSG group (p: 0.033). No significant difference in survival was registered. Multivariate analysis identified age at diagnosis, diffuse-type tumor, pN and LODDS as independent predictors of worse prognosis. CONCLUSIONS: LSG can be safely performed for the treatment of AGC, allowing faster postoperative recovery.

The Sleeping Remnant. Effect of Roux-En-Y Gastric Bypass on Plasma Levels of Gastric Biomarkers in Morbidly Obese Women: A Prospective Longitudinal Study.

BACKGROUND: Morpho-functional modifications of the gastric remnant after Roux-en-Y gastric bypass (RYGB) have not been completely defined, due to its inaccessibility for bioptic mapping. The aim of the study is to evaluate such modifications using Gastropanel®, a non-invasive blood test cross-checking four gastric biomarkers, able to provide a snapshot of mucosa conditions. SUBJECTS AND METHODS: Twenty-four women undergoing RYGB were prospectively enrolled. Gastropanel® parameters (pepsinogens, Gastrin-17 and immunoglobulins against Helicobacter pylori), biometrical/clinical data were collected preoperatively and at 6-months follow-up. RESULTS: All parameters showed significant reduction (p < 0.05). Pepsinogen I reduction correlated with BMI percent decrease. CONCLUSIONS: The exclusion of food transit is responsible for significant drop in gastric output, hardly representing a risk factor in the remnant carcinogenesis, being unexposed to alimentary carcinogenic agents.

Morphological Changes in the Carotid Artery Intima after Gastric Bypass for Morbid Obesity.

BACKGROUND: Carotid intima-media thickness (C-IMT) can be considered as an early marker of atherosclerosis, thus representing a reliable cardiovascular risk predictor. Bariatric surgery decreases the burden of cardiovascular disease in obese patients through complex mechanisms, of which weight loss is merely the most evident epiphenomenon. The aim of this study is to evaluate C-IMT variations in patients undergoing Roux-en-Y gastric bypass (RYGB) and possible correlations with biometric parameters and cardiovascular risk factors. METHODS: Thirty patients undergoing RYGB for morbid obesity were enrolled for carotid artery B-mode ultrasound evaluation before surgery and at 1-, 3-, 6-, and 12-month follow-up; C-IMT was recorded at three levels (bulb, common, and internal carotid). At each one of the follow-ups, biometric and serohematic parameters were also collected. RESULTS: The 22 patients who completed the follow-up and were included in the study showed significant C-IMT reduction at all three levels at 12-month follow-up (p < 0.001). Along with a significant BMI reduction and diabetes/hypertension remission, we found a considerable decrease in total cholesterol (219 vs 164 mg/dl; p < 0.001) and uric acid (5.6 vs 4.5 mg/dl; p < 0.01) and a significant increase in HDL cholesterol (43.9vs59.2 mg/dl; p < 0.001). The data imply that the mean 10-year cardiovascular risk score drops by nearly 50 % (5.7 ± 5.6 vs. 2.9 ± 2.7 %, p < 0.001) according to Framingham cardiovascular risk stratification. CONCLUSIONS: RYGB is associated with significant decrease in C-IMT at 1 year. Pathophysiologic processes underlying such a variation, probably involving lipid and urate metabolism and their correlation with cardiovascular risk reduction should be confirmed by long-term prospective trials.

Laparoscopic resection of tailgut cysts: the size is not the issue.

INTRODUCTION: Tailgut cysts are rare retrorectal cystic lesions usually treated by surgical resection, even where asymptomatic, due to the risk of malignancy and recurrence. In the last 20 years, the laparoscopic abdominal approach has been gaining consensus for its better visualization of pelvic structures and minimal invasiveness. CASE REPORT: We present the case of the biggest tailgut cysts managed laparoscopically reported so far. DISCUSSION: Mostly asymptomatic, diagnosis of tailgut cysts is often fortuitous during routine examination. Their malignant transformation is estimated being 14.1% of cases. MRI is particularly indicated to lead the surgical approach, given its superior resolution in soft tissues and assessment of local invasion. Surgical resection is the therapy of choice, performed with different approaches: the laparoscopic abdominal technique, performed by surgeons with expertise in pelvic laparoscopic surgery, allows the best visualization of pelvic viscera with lesser morbidity. Due to rupture and seeding risks, the laparoscopic approach should not be performed if there is any suspicion of malignancy. CONCLUSION: Our case substantiates safety and feasibility of laparoscopic tailgut cysts management, even of large-size cysts. Preoperative imaging is crucial to assess the possible malignancy of the lesion and, in that case, to perform a laparotomic approach. KEY WORDS: Laparoscopy, Retrorectal space, Tailgut Cyst.

Road Running After Gastric Bypass for Morbid Obesity: Rationale and Results of a New Protocol.

BACKGROUND: In recent years, the pandemic explosion of obesity has led to the definition of a pre-eminent therapeutic role for bariatric surgery, confining physical activity to a success parameter of surgery rather than a primary prevention measure. The aim of this study is to evaluate the role for aerobic physical activity (road running) in strengthening the metabolic and psychosocial effects of bariatric surgery. METHODS: Ten patients who underwent gastric bypass for morbid obesity were submitted to an intensive program of road running training, aimed at completing a 10.5-km competition in September 2013. Inclusion criteria included age (<50), BMI (<35), suitability for sport activity, and good compliance. A cohort of 10 patients excluded for logistical issues were enrolled as a control group. During the training period, patients were submitted to biometrical, sport performance, cardiopulmonary, metabolic, and psychiatric evaluations. RESULTS: Protocol adherence was 70 %; no physical injury was registered among participants. More than weight loss (BMI 29.3 to 27.1), the runners experienced a redistribution of body mass with significant differences in fat percentage and waist/hip ratio. Participants had a significant running performance improvement and, differently from the controls, a significant amelioration of echocardiographic and cardiopulmonary parameters, predicting a reduction in cardiovascular risk. Psychiatric evaluation underlined a tendency to a reduction in anxiety, depression, and general psychopathology symptoms. CONCLUSIONS: Road running seems to have an important supporting role in boosting bariatric surgery results. The utilization of monitored and regulated training programs represents a fundamental prerequisite to achieving satisfactory results and patient compliance.