Radical gastric cancer surgery results in widespread upregulation of pro-tumourigenic intraperitoneal cytokines.

BACKGROUND: Radical surgical resection is the mainstay of curative treatment for oesophagogastric malignancy. However, survival and recurrence rates remain poor. Theoretical data suggests that the inflammatory response to surgery can promote tumour recurrence. The local and systemic inflammatory response to radical oesophagogastric cancer surgery has not been fully characterized. We aimed to measure this response, particularly factors associated with tumour implantation. METHODS: Consecutive patients undergoing radical junctional or gastric cancer resection over 12 months were recruited. Repeated serum and adipose tissue were collected intra-operatively. Adipose tissue was collected adjacent and remote to the tumour, and cytokine messenger RNA (mRNA) expression was measured. Post-operatively, daily serum was collected for 7 days, and analysed for inflammatory cell profile and cytokine concentration. RESULTS: There were nine patients recruited (67.1 ± 2.1 years). mRNA expression of interleukin-6 (IL-6), CC-chemokine ligand-2 and IL-1ß increased in adipose tissue intra-operatively (P < 0.05), equally both adjacent and remote from the tumour site. Serum IL-6 concentration increased from 23.3 pg/mL to 161.8 pg/mL intra-operatively (P < 0.05) before falling steadily to 35.7 pg/mL post-operatively (P < 0.05). Serum tumour necrosis factor-α was elevated throughout, and IL-1ß levels were unaffected. Leukocyte and neutrophil populations increased, while T-cell and dendritic cell populations decreased intra-operatively (P < 0.05). CONCLUSION: Radical surgery dramatically upregulates the expression of pro-tumourigenic cytokines in the peritoneum. There is also a marked systemic immune and inflammatory response to surgery, including downregulation of T-cell and dendritic cell populations. This offers two potential pathways that may facilitate tumour progression - local inflammation promoting peritoneal adherence and implantation, and secondary suppression of immunosurveillance due to circulating inflammatory response.

Single frequency bioelectrical impedance is a poor method for determining fat mass in moderately obese women.

BACKGROUND: The primary aim of weight loss intervention in obesity is the loss of fat mass (FM). Hence, determinations of changes in FM and fat free mass (FFM) during weight loss are of clinical value. The authors compared the clinical utility of SkinFold Thickness (SKF), tetrapolar bioelectrical impedance analysis (BIA) and a body mass index (BMI) based calculation, in determining changes in percentage of fat mass (delta%FM). METHODS: Using dual X-ray absorptiometry (DEXA) measurements of %FM as a standard, BIA, SKF and BMI were compared in 41 moderately obese women (BMI 30-35) before and after significant weight loss (-13.9 +/- 5.8 kg). RESULTS: When measuring fat mass loss, SKF was precise and accurate with a bias of +0.86 +/- 6.16 %, while the BMI-based estimation had a systematic bias of +6.36 +/- 6.04 % (r2 = 0.791, P < 0.001). BIA using the Lukaski formula had a bias of +5.22 % and limits of agreement that approached the magnitude of the measurement (+/- 20.82 %), thus providing no information. In contrast, BIA using the Segal formula had a systematic bias of +7.81% (r2 = 0.636, P < 0.001) and gave narrower limits of agreement (+/- 8.34 %). CONCLUSION: For measuring changes in %FM with weight loss, BIA has no clinical value using the Lukaski formula, and using the Segal formula BIA provided no additional information to that given by BMI. We show that BIA instrument variables confound the estimates of %FM achieved by the BMI component of the Lukaski and Segal formulas.

Concurrent Large Para-oesophageal Hiatal Hernia Repair and Laparoscopic Adjustable Gastric Banding: Results from 5-year Follow Up.

OBJECTIVE: The objective of the study is to identify the efficacy and safety of combining laparoscopic adjustable gastric banding with repair of large para-oesophageal hernias. BACKGROUND: Para-oesophageal hernias are more common in the obese with higher recurrence rates following repair. The effect and safety of combining para-oesophageal hernia repair with laparoscopic adjustable gastric banding is unknown. METHODS: One-hundred fourteen consecutive patients undergoing primary laparoscopic adjustable gastric banding with concurrent repair of a large para-oesophageal hernia were prospectively identified and matched to a control group undergoing primary laparoscopic adjustable gastric banding only. Weight loss and complication data were retrieved from a prospectively maintained database, and a standardised bariatric outcome questionnaire was used to assess post-operative symptoms, satisfaction with surgery and satiety scores. RESULTS: At a mean follow up of 4.9 ± 2.1 years, total weight loss was 16.4 ± 9.9% in the hernia repair group and 17.6 ± 12.6% in the control group (p = 0.949), with 17 vs. 11% loss to follow up rates (p = 0.246). No statistically significant difference in revisional surgery rate and symptomatic recurrence of hiatal hernia was documented in four patients in the hernia repair group (3.5%). No statistically significant difference in mean reflux (9.9 vs. 10.3, p = 0.821), dysphagia (20.7 vs. 20.1, p = 0.630) or satiety scores was identified. CONCLUSIONS: Concurrent repair of large para-oesophageal hiatal hernia and laparoscopic adjustable gastric banding placement is safe and effective both in terms of symptom control and weight loss over the intermediate term. In obese patients with large hiatal hernias, consideration should be given to combining repair of the hernia with a bariatric procedure.

Motivation, readiness to change, and weight loss following adjustable gastric band surgery.

High levels of readiness to change (RTC) are considered critical to the long-term success of weight management programs including bariatric surgery. However, there are no data to support this assertion. We hypothesize that RTC level will not influence weight outcomes following surgery. In 227 consecutive patients undergoing adjustable gastric banding surgery, we recorded reasons for seeking surgery, and RTC measured with the University of Rhode Island Change Assessment. Scores were blinded until study completion. The primary outcome measure was percentage of excess BMI loss at 2 years (%EBMIL-2); others included compliance and surgical complications. Of 227 subjects, 204 (90%) had weight measurement at 2 years. There was no significant correlation between RTC score and %EBMIL-2 (r = 0.047, P = 0.5). Using the median split for RTC score the lowest 102 subjects mean %EBMIL-2 was 52.9 +/- 26.9% and the highest 52.2 +/- 28.3%, P = 0.869. There was no weight loss difference between highest and lowest quartiles, or a nonlinear relationship between weight loss and RTC score. There was no significant relationship between RCT score and compliance, or likelihood of complications. Those motivated by appearance were more likely to be younger women who lost more weight at 2 years. Poor attendance at follow-up visits was associated with less weight loss, especially in men. Measures of RTC did not predict weight loss, compliance, or surgical complications. Caution is advised when using assessments of RTC to predict outcomes of bariatric surgery.

Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: a randomized controlled study.

BACKGROUND: Class III obese patients have altered respiratory mechanics, which are further impaired in the supine position. The authors explored the hypothesis that preoxygenation in the 25 degrees head-up position allows a greater safety margin for induction of anesthesia than the supine position. METHODS: A randomized controlled trial measured oxygen saturation and the desaturation safety period after 3 min of preoxygenation in 42 consecutive (male:female 13:29) severely obese (body mass index > 40 kg/m) patients who were undergoing laparoscopic adjustable gastric band surgery and were randomly assigned to the supine position or the 25 degrees head-up position. Serial arterial blood gases were taken before and after preoxygenation and 90 s after induction. After induction, ventilation was delayed until blood oxygen saturation reached 92%, and this desaturation safety period was recorded. RESULTS: The mean body mass indexes for the supine and 25 degrees head-up groups were 47.3 and 44.9 kg/m, respectively (P = 0.18). The group randomly assigned to the 25 degrees head-up position achieved higher preinduction oxygen tensions (442 +/- 104 vs. 360 +/- 99 mmHg; P = 0.012) and took longer to reach an oxygen saturation of 92% (201 +/- 55 vs. 155 +/- 69 s; P = 0.023). There was a strong positive correlation between the induction oxygen tension achieved and the time to reach an oxygen saturation of 92% (r = 0.51, P = 0.001). There were no adverse events associated with the study. CONCLUSION: Preoxygenation in the 25 degrees head-up position achieves 23% higher oxygen tensions, allowing a clinically significant increase in the desaturation safety period--greater time for intubation and airway control. Induction in the 25 degrees head-up position may provide a greater safety margin for airway control.