Psychological Aspects of Treatment with Intragastric Balloon for Management of Obesity: A Systematic Review of the Literature

INTRODUCTION

Optimizing maintenance of weight loss for people with obesity following intragastric balloon (IGB) therapy hinges on the degree to which health care providers can recognize both the impact of emotional problems and mood difficulties on their capacity to self-manage, and requirements for additional support. However, there is limited research on the psychological correlates of IGB therapy. This systematic review, for the first time, attempts to identify and synthesize the empirical evidence for the reciprocal influence between psychological variables and IGB outcomes.

METHODS

A literature search was performed in the PubMed, SCOPUS, MEDLINE, and Google Scholar databases. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed using rigorous inclusion criteria and screening by at least 2 reviewers. The selected articles were assessed for quality using the Strengthening the Reporting of Observational Studies Epidemiology (STROBE) checklist. Data were extracted to address the review aims and presented as a narrative synthesis. The review protocol was preregistered (Prospero CRD42019121291).

RESULTS

A total of 16,179 titles, 14,369 abstracts, and 51 full-text articles were screened, of which 16 studies were included. Findings suggest that female gender, older age, basic educational level, and single/divorced civil status, together with lower levels of depression, binge eating, higher perceived quality of life, and motivation to change were predictors of enhanced IGB treatment outcomes. Dissatisfaction with treatment was higher in those with impaired obesity-related social-life difficulties. The IGB treatment was effective in reducing weight and improving depression, anxiety, eating disorder symptoms, and the overall life quality of patients with obesity - mainly within 6 months from the device positioning and in conjunction with conventional therapies.

DISCUSSION/CONCLUSION

In line with the available literature on obesity and bariatric surgery interventions, poor mental health appears to be an important barrier for successful weight loss among patients with obesity undergoing IGB treatment. In order to improve the efficacy and effectiveness of the IGB therapy, more comprehensive and standardized studies are needed to provide insight into the psychological mechanisms maintaining weight management issues.

Videothoracoscopic approach to stage I non-small cell lung cancer

AIM

Aim of this study is to evaluate the validity of videothoracoscopic staging and treatment in a twenty-year-long series of 286 VATS lobectomies for Clinical Stage I NSCLC.

MATERIAL OF STUDY

We retrospectively reviewed 1549 candidates to resection after conventional staging from November 1991 to December 2013, and routinely submitted to videothoracoscopy immediately before the procedure. Patients deemed operable at videoexploration were resected by thoracoscopy or thoracotomy. Out of 534 VATS resections 286 thoracoscopic lobectomies for clinical stage I cancers were performed with strict indications and standardized technique; more advanced tumours were converted even when thoracoscopically resectable. Impact of preliminary videothoracoscopy and and longterm Kaplan-Meier survival was analyzed.

RESULTS AND DISCUSSION

Out of 1549 patients, videothoracoscopy disclosed inoperability in 62 (4 %), mostly for pleural carcinosis (33pts.-2.1%) or mediastinal infiltration (22pts-1.4%). 534 (34.5%) patients had videothoracoscopic resection (286 lobectomies, 7 pneumonectomies, 241 wedge resections), 919 (59.3%) had thoracotomy resection, 34 (2.2%) had an exploratory thoracotomy (ET). Thoracoscopy had an accuracy rate of 72.4%, was reliable in excluding unresectability (NPV 0.95), and decreased the rate of ETs to 2.1%, ,sparing 596 (38.5%) thoracotomies. There was no intraoperative mortality or recurrence. Stage I patients had 83.8% 3-yr survival and 64.3% 5-yr survival. Five-year survival was significantly better (p=0.004) for T1N0 patients (70%) than T2N0 (55%) and for patients younger than 55 (86.4%) or with lesion < 2 cm (80.8%).

CONCLUSIONS

Preliminary videothoracoscopy reliably assesses tumor resectability and feasibility of thoracoscopic resection, limiting unnecessary thoracotomies. Videolobectomies are safe and survival is comparable to open lobectomy.

KEY WORDS

Lobectomy, Lung cancer, Minimally invasive surgery, Thoracoscopy, VATS.

[Psychiatric features before and after intervention: a study of patients affected by severe obesity undergoing adjustable gastric banding]

AIM

This study identifies psychological features and the evolution of psychiatric symptoms in a group of patients affected by obesity, who underwent adjustable gastric banding.

MATERIALS AND METHODS

In this group, other than clinical visit, test SCL-90 is made in preoperative time. In postoperative SCL-90, TAS and BES were carried out. Patients evaluated before and after bariatric surgery were 220 and 115, respectively. SCL-90 test made before bariatric surgery showed high values (>0.7) for cluster related to somatization, interpersonal sensitivity, paranoid ideation, depression and obsessive compulsive disorder.

DISCUSSION

Depression symptoms were more important in patients undergoing endogastric balloon placement (mean value of 0.9). Anxious symptoms showed a mean value of 0.73 in patients undergoing endogastric balloon placement as compared to a mean value of 0.52 in patients undergoing gastric banding.

CONCLUSIONS

Our findings show that in patients undergoing bariatric surgery, depressive symptoms are more common preoperatively and normalize at follow-up. This confirms that a possible cause of depression is obesity. The present study also shows that anxious symptoms are lower in obese patients.

The I148M PNPLA3 polymorphism influences serum adiponectin in patients with fatty liver and healthy controls

Background

Reduced adiponectin is implicated in the pathogenesis of nonalcoholic fatty liver disease (NAFLD) and steatohepatitis (NASH), and the I148M Patatin-like phospholipase domain-containing 3 (PNPLA3) polymorphism predisposes to NAFLD and liver damage progression in NASH and chronic hepatitis C (CHC) by still undefined mechanisms, possibly involving regulation of adipose tissue function. Aim of this study was to evaluate whether the I148M PNPLA3 polymorphism influences serum adiponectin in liver diseases and healthy controls.

Methods

To this end, we considered 144 consecutive Italian patients with NAFLD, 261 with CHC, 35 severely obese subjects, and 257 healthy controls with very low probability of steatosis, all with complete clinical and genetic characterization, including adiponectin (ADIPOQ) genotype. PNPLA3 rs738409 (I148M) and ADIPOQ genotypes were evaluated by Taqman assays, serum adiponectin by ELISA. Adiponectin mRNA levels were evaluated by quantitative real-time PCR in the visceral adipose tissue (VAT) of 35 obese subjects undergoing bariatric surgery.

Results

Adiponectin levels were independently associated with the risk of NAFLD and with the histological severity of the disease. Adiponectin levels decreased with the number of 148 M PNPLA3 alleles at risk of NASH both in patients with NAFLD (p = 0.03), and in healthy subjects (p = 0.04). At multivariate analysis, PNPLA3 148 M alleles were associated with low adiponectin levels (<6 mg/ml, median value) independently of NAFLD diagnosis, age, gender, BMI, and ADIPOQ genotype (OR 1.67, 95% c.i. 1.07-2.1 for each 148 M allele). The p.148 M PNPLA3 variant was associated with decreased adiponectin mRNA levels in the VAT of obese patients (p < 0.05) even in the absence of NASH. In contrast, in CHC, characterized by adiponectin resistance, low adiponectin was associated with male gender and steatosis, but not with PNPLA3 and ADIPOQ genotypes and viral features.

Conclusions

The I148M PNPLA3 variant is associated with adiponectin levels in patients with NAFLD and in healthy subjects, but in the presence of adiponectin resistance not in CHC patients. The I148M PNPLA3 genotype may represent a genetic determinant of serum adiponectin levels. Modulation of serum adiponectin might be involved in mediating the susceptibility to steatosis, NASH, and hepatocellular carcinoma in carriers of the 148 M PNPLA3 variant without CHC, with potential therapeutic implications.

Inflammatory and prothrombotic parameters in normotensive non-diabetic obese women: effect of weight loss obtained by gastric banding

Hypertension and diabetes are known risk factors for obesity-related thrombosis, but several studies have shown that obesity is characterised by a potentially prothrombotic inflammatory state because of activated coagulation and impaired fibrinolysis. In order to verify if obese patients-unaffected by hypertension, diabetes, dyslipidemia, cigarette smoking or inflammatory diseases-show increased prothrombotic markers and whether the weight loss induced by gastric banding normalises such parameters. Plasma levels of C reactive protein (CRP), fibrinogen, plasminogen activator inhibitor-1 (PAI-1), von Willebrand factor (VWF) and factor VII (FVII) were measured in 25 women with isolated obesity prior to, as well as 3, 6 and 12 months subsequent to gastric banding. Twenty-five healthy women served as a baseline control group. The obese women had higher CRP (p = 0.0001), fibrinogen (p = 0.014), PAI-1 (p = 0.003), VWF (p = 0.004) and FVII levels (p = 0.0001) than the normal controls, and their body mass index (BMI) positively correlated with CRP (r = 0.462, p = 0.02), fibrinogen (r = 0.426, p = 0.04) and PAI-1 (r = 0.468, p = 0.02). Twelve months after gastric banding, the median BMI had decreased from 40.0 to 34.9 (p = 0.0001); CRP from 4.18 to 1.69 μg/ml (p = 0.01); fibrinogen from 389 to 318 mg/dl (p = 0.0001); PAI-1 from 32.1 to 12.0 UI/ml (p = 0.003); VWF from 144 to 120% (p = 0.0001); and FVII from 134 to 112% (p = 0.002). Even in the absence of major cardiovascular risk factors, obese patients are characterised by a prothrombotic state. The weight loss induced by gastric banding decreases the parameters of inflammation, coagulation and impaired fibrinolysis, thus potentially reducing the thrombotic risk.

Trans-obturator colonic suspension during Altemeier's operation for full-thickness rectal prolapse: preliminary results with a new technique

AIM

With the aim of reducing recurrence after perineal surgery for full-thickness rectal prolapse, a new operation consisting of a trans-obturator colonic suspension during Altemeier's operation has been developed.

METHOD

Eighteen women with full-thickness rectal prolapse were examined clinically, with validated quality of life and continence scores, colonoscopy, anorectal manometry, anal EMG and sacral reflex latency. Ten had a newly diagnosed and eight a recurrent prolapse. The Altemeier operation was combined with a levatorplasty in all cases using two porcine collagen prostheses sutured to the descending colon and passed through the trans-obturator space bilaterally. The operation was completed by a manual or stapled colo-anal anastomosis. Clinical examination, with quality of life and continence scores, anorectal manometry, EMG and sacral reflex latency, was scheduled during follow up, with the recurrence of prolapse as the primary outcome measure.

RESULTS

There were no recurrences at 30 months. There was no mortality and no complications. All patients experienced significant improvement in quality of life and faecal continence scores (P<0.01). Surgery did not affect anorectal pressures or sacral reflex latencies.

CONCLUSION

The new technique appears to be relatively easy to perform and is complication free with no recurrence after a short period of follow up. A larger study with appropriate controls and longer follow up is now needed to assess its real effectiveness in reducing the risk of recurrence.

The APOC3 T-455C and C-482T promoter region polymorphisms are not associated with the severity of liver damage independently of PNPLA3 I148M genotype in patients with nonalcoholic fatty liver

BACKGROUND & AIMS

The T-455C and C-482T APOC3 promoter region polymorphisms (SNPs) have recently been reported to predispose to dyslipidemia, insulin resistance, and nonalcoholic fatty liver disease (NAFLD) in Indian subjects, but the association with liver damage has not been evaluated so far. The aim was to assess the association between APOC3 SNPs and liver damage in Caucasian patients.

METHODS

We considered 437 Italian patients with histological diagnosis of NAFLD (including 137 children, 120 morbid obese) and 316 healthy controls, 71 Italian family trios, and 321 patients from the UK. APOC3 SNPs were determined by sequencing, allele-specific oligonucleotide probes and PCR-restriction fragment length polymorphism analysis, hepatic APOC3 mRNA levels by real-time PCR.

RESULTS

APOC3 SNPs were not associated with NAFLD in Italian subjects, although a borderline significance for the transmission of the -455T allele was observed in the family study. Homozygosity for the APOC3 wild-type genotype (APOC3 WT) was associated with a more favorable lipid profile in control subjects, and consistently with lower hepatic APOC3 mRNA levels in obese patients without diabetes. However, APOC3 SNPs, alone or in combination, were not associated with insulin resistance, altered lipid levels, liver enzymes, and with liver damage (severity of steatosis, nonalcoholic steatohepatitis, and moderate/severe fibrosis) in Italian as well as in UK patients, and in the whole cohort. Stratification for the I148M PNPLA3 mutation, associated with the susceptibility to NASH, did not alter the results.

CONCLUSIONS

APOC3 genotype is not associated with progressive liver damage in Caucasian patients with NAFLD.

Treatment of band erosion: feasibility and safety of endoscopic band removal

BACKGROUND

Band erosion is reported with a highly variable incidence (0.3-14%) after laparoscopic adjustable gastric banding. Removal of the band is mandatory because the patient regains weight and may become symptomatic, but no consensus exists about the best method, surgical or endoscopic, for this purpose. This study aimed to evaluate the feasibility and effectiveness of endoscopic management of band erosion.

METHODS

In this study, 23 patients were treated for band erosion after gastric banding: 8 from the authors' series of 951 patients (incidence, 0.84%) and 15 referred to the authors' surgical department from other hospitals. The endoscopic method of band removal was used in 20 cases. Because of complications associated with erosion, three patients were submitted instead to laparoscopic removal.

RESULTS

Endoscopic removal of the band was successful for 16 of 20 patients. Four cases required conversion of the procedure to surgery: in one case due to complications with the endoscopic cutting wire and in the three remaining cases due to dense perigastric adhesions blocking the band. The follow-up evaluation of the patients who had the endoscopic removal was uneventful, with quick discharge at resumption of oral feeding. The patients who underwent laparoscopic removal had a longer hospital stay, and one patient had a leak from the anterior gastrotomy.

CONCLUSIONS

Despite a few complications, endoscopic removal seems to be the procedure of choice for the treatment of band erosion. It allows quick resumption of oral feeding and rapid discharge of patients and appears to be safer and more effective than laparoscopic removal. Conversion to surgery is unlikely but possible. Therefore, the authors always recommend that the procedure be performed in the operating room.

What is the benefit of a new stapler device in the surgical treatment of obstructed defecation? Three-year outcomes from a randomized controlled trial

PURPOSE

A randomized study was conducted to compare the clinical and functional outcomes of the stapled transanal rectal resection, using the traditional 2 circular staplers and a new, curved stapler device in patients with obstructed defecation caused by rectal intussusception and rectocele. Stapled transanal rectal resection gives good midterm results in patients with obstructed defecation syndrome, but the limited capacity of the casing of the circular stapler and the impossibility to control the positioning of the rectal wall and the firing of staples may result in incomplete removal of the prolapsed tissues, or serious complications. The new curved multifire stapler could avoid these drawbacks.

METHODS

From January to December 2006, 100 women were selected, with clinical examination, constipation score, colonoscopy, anorectal manometry, and perineography, and randomly assigned to 2 groups: 50 patients underwent stapled transanal rectal resection with 2 traditional circular staplers (STARR group) and 50 had the same operation with a new, curved multifire stapler (TRANSTAR group). Patients were followed up with clinical examination, constipation score, and colpocystodefecography, with the recurrence rate as the primary outcome measure.

RESULTS

Recurrence rates at 3 years were 12.0% in STARR group and 0 in the TRANSTAR group (P = .035). Operating time was significantly shorter in the STARR group (P = .008). Complications were 2 bleeds (4%) in the STARR group and 1 tear of the vagina in the TRANSTAR group. The incidence of fecal urgency was 34.0% in the STARR group and 14.0% in the TRANSTAR group (P = .035). All symptoms and defecographic parameters significantly improved after the operation (P < .001) without differences between groups.

CONCLUSIONS

The curved Contour Transtar stapler device did not appear to offer significant advantages over the traditional PPH-01 device during the operation or in the clinical and functional outcomes. However, the lower incidence of fecal urgency and recurrences might justify the higher cost of the new stapler.

Homozygosity for the patatin-like phospholipase-3/adiponutrin I148M polymorphism influences liver fibrosis in patients with nonalcoholic fatty liver disease

Inherited factors play a major role in the predisposition to nonalcoholic fatty liver disease (NAFLD), and the rs738409 C-->G polymorphism of PNPLA3/adiponutrin, encoding for the isoleucine-to-methionine substitution at residue 148 (I148M) protein variant, has recently been recognized as a major determinant of liver fat content. However, the effect of the rs738409 polymorphism on the severity of liver fibrosis in patients with NAFLD is still unknown. In this study, we considered 253 Italian patients, 179 healthy controls, and 71 family trios with an affected child with NAFLD. Analyses were replicated in 321 patients from the United Kingdom. The rs738409 polymorphism was determined by TaqMan assays. Liver histology was scored according to Kleiner et al. Hepatic expression of genes regulating liver damage was assessed by real-time polymerase chain reaction in 52 patients. The rs738409 GG genotype was more prevalent in patients than in controls (14% versus 3%, adjusted odds ratio [OR] = 3.29, 95% confidence interval [CI] = 1.8-6.9), and in the family study, the G allele was overtransmitted to affected children (P = 0.001). In Italian and United Kingdom patients, adiponutrin genotype influenced alanine aminotransferase levels and the severity of steatosis. Adiponutrin genotype was associated with the expression of genes involved in the steatosis-related liver damage, including the proapoptotic molecule Fas ligand. In the whole series combined, adiponutrin genotype was associated with steatosis grade >1 (OR = 1.35, 95% CI = 1.04-1.76), nonalcoholic steatohepatitis (OR = 1.5, 95% CI = 1.12-2.04), and fibrosis stage >1 (OR = 1.5, 95% CI = 1.09-2.12), independent of age, body mass index, and diabetes. Adiponutrin genotype demonstrated a dose effect with heterozygote risk intermediate between CC and GG homozygotes.

CONCLUSION

In patients with NAFLD, adiponutrin rs738409 C-->G genotype, encoding for I148M, is associated with the severity of steatosis and fibrosis and the presence of nonalcoholic steatohepatitis.

Homozygosity for the patatin-like phospholipase-3/adiponutrin I148M polymorphism influences liver fibrosis in patients with nonalcoholic fatty liver disease

Inherited factors play a major role in the predisposition to nonalcoholic fatty liver disease (NAFLD), and the rs738409 C-->G polymorphism of PNPLA3/adiponutrin, encoding for the isoleucine-to-methionine substitution at residue 148 (I148M) protein variant, has recently been recognized as a major determinant of liver fat content. However, the effect of the rs738409 polymorphism on the severity of liver fibrosis in patients with NAFLD is still unknown. In this study, we considered 253 Italian patients, 179 healthy controls, and 71 family trios with an affected child with NAFLD. Analyses were replicated in 321 patients from the United Kingdom. The rs738409 polymorphism was determined by TaqMan assays. Liver histology was scored according to Kleiner et al. Hepatic expression of genes regulating liver damage was assessed by real-time polymerase chain reaction in 52 patients. The rs738409 GG genotype was more prevalent in patients than in controls (14% versus 3%, adjusted odds ratio [OR] = 3.29, 95% confidence interval [CI] = 1.8-6.9), and in the family study, the G allele was overtransmitted to affected children (P = 0.001). In Italian and United Kingdom patients, adiponutrin genotype influenced alanine aminotransferase levels and the severity of steatosis. Adiponutrin genotype was associated with the expression of genes involved in the steatosis-related liver damage, including the proapoptotic molecule Fas ligand. In the whole series combined, adiponutrin genotype was associated with steatosis grade >1 (OR = 1.35, 95% CI = 1.04-1.76), nonalcoholic steatohepatitis (OR = 1.5, 95% CI = 1.12-2.04), and fibrosis stage >1 (OR = 1.5, 95% CI = 1.09-2.12), independent of age, body mass index, and diabetes. Adiponutrin genotype demonstrated a dose effect with heterozygote risk intermediate between CC and GG homozygotes.

CONCLUSION

In patients with NAFLD, adiponutrin rs738409 C-->G genotype, encoding for I148M, is associated with the severity of steatosis and fibrosis and the presence of nonalcoholic steatohepatitis.

HFE genotype, parenchymal iron accumulation, and liver fibrosis in patients with nonalcoholic fatty liver disease

BACKGROUND & AIMS

Mutations in the hemochromatosis gene (HFE) (C282Y and H63D) lead to parenchymal iron accumulation, hemochromatosis, and liver damage. We investigated whether these factors also contribute to the progression of fibrosis in patients with nonalcoholic fatty liver disease (NAFLD).

METHODS

We studied clinical, histologic (liver biopsy samples for hepatocellular iron accumulation), serologic (iron and enzyme levels), and genetic (HFE genotype) data from 587 patients from Italy with NAFLD and 184 control subjects.

RESULTS

Iron accumulation predominantly in hepatocyes was associated with a 1.7-fold higher risk of a fibrosis stage greater than 1 (95% confidence interval [CI]: 1.2-2.3), compared with the absence of siderosis (after adjustment for age, body mass index, glucose tolerance status, and alanine aminotransferase level). Nonparenchymal/mixed siderosis was not associated with moderate/severe fibrosis (odds ratio, 0.72; 95% CI: 0.50-1.01). Hepatocellular siderosis was more prevalent in patients with HFE mutations than in those without; approximately one third of patients with HFE mutations had parenchymal iron accumulation (range, 29.8%-35.7%, depending on HFE genotype). Predominantly hepatocellular iron accumulation occurred in 52.7% of cases of patients with HFE mutations. There was no significant association between either the presence of HFE mutations or specific HFE genotypes and the severity of liver fibrosis.

CONCLUSIONS

Iron deposition predominantly in hepatocyes is associated with more severe liver damage in patients with NAFLD. However, HFE mutations cannot be used to identify patients with hepatocellular iron accumulation.

Genetic variants regulating insulin receptor signalling are associated with the severity of liver damage in patients with non-alcoholic fatty liver disease

BACKGROUND/AIMS

The aim of this study was to assess the effect of functional ENPP1(ectoenzyme nucleotide pyrophosphate phosphodiesterase 1)/PC-1 (plasma cell antigen-1) and IRS-1 (insulin receptor substrate-1) polymorphisms influencing insulin receptor activity on liver damage in non-alcoholic fatty liver disease (NAFLD), the hepatic manifestation of the metabolic syndrome, whose progression is associated with the severity of insulin resistance.

PATIENTS AND METHODS

702 patients with biopsy-proven NAFLD from Italy and the UK, and 310 healthy controls. The Lys121Gln ENPP1/PC-1 and the Gly972Arg IRS-1 polymorphisms were evaluated by restriction analysis. Fibrosis was evaluated according to Kleiner. Insulin signalling activity was evaluated by measuring phosphoAKT levels by western blotting in a subset of obese non-diabetic patients.

RESULTS

The ENPP1 121Gln and IRS-1 972Arg polymorphisms were detected in 28.7% and 18.1% of patients and associated with increased body weight/dyslipidaemia and diabetes risk, respectively. The ENPP1 121Gln allele was significantly associated with increased prevalence of fibrosis stage >1 and >2, which was higher in subjects also positive for the 972Arg IRS-1 polymorphism. At multivariate analysis, the presence of the ENPP1 121Gln and IRS-1 972Arg polymorphisms was independently associated with fibrosis >1 (OR 1.55, 95% CI 1.24 to 1.97; and OR 1.57, 95% CI 1.12 to 2.23, respectively). Both polymorphisms were associated with a marked reduction of approximately 70% of AKT activation status, reflecting insulin resistance and disease severity, in obese patients with NAFLD.

CONCLUSIONS

The ENPP1 121Gln and IRS-1 972Arg polymorphisms affecting insulin receptor activity predispose to liver damage and decrease hepatic insulin signalling in patients with NAFLD. Defective insulin signalling may play a causal role in the progression of liver damage in NAFLD.

Prospective clinical and functional results of combined rectal and urogynecologic surgery in complex pelvic floor disorders

BACKGROUND

The aim of this prospective study was to evaluate the results of combined rectal and urogynecologic surgery in women with associated obstructed defecation, urinary incontinence, or genital prolapse.

METHODS

One hundred forty-two selected patients with obstructed defecation in isolation or associated with urinary incontinence, enterocele, or genital prolapse were consecutively operated on by stapled transanal rectal resection alone or associated with transobturator tape, vaginal repair of the enterocele, or vaginal hysterectomy, respectively, and followed up by clinical controls and defecography.

RESULTS

At 2 years, all symptom, quality-of-life, and defecographic parameters had significantly improved in all groups (P < .001). The association with hysterectomy showed higher risk for severe complications, longer operative time, hospital stay, and time of inability (P < .001). Recurrence of urinary incontinence was observed in 3 of 24 patients, while 2 of 21 showed residual vaginal prolapse.

CONCLUSION

The combination of rectal and urogynecologic surgery is effective, with higher morbidity in the association with vaginal hysterectomy. Randomized trials comparing surgery in 1 and more stages and longer follow-up are necessary for a definitive conclusion.

Increased expression and activity of the transcription factor FOXO1 in nonalcoholic steatohepatitis

OBJECTIVE

Nonalcoholic fatty liver, affecting 34% of the U.S. population, is characterized by hepatic insulin resistance, which is more marked in the presence of steatohepatitis, and frequently precedes hyperglycemia. The molecular mechanisms underlying the relationship between fatty liver and insulin resistance are still undergoing definition and have not been evaluated in humans. Our aim was to evaluate the relationship between insulin resistance and the expression and regulation of forkhead box-containing protein O subfamily-1 (FOXO1), a transcription factor that mediates the effect of insulin on the gluconeogenic genes PEPCK and glucose-6-phosphatase catalytic subunit (G6PC).

RESEARCH DESIGN AND METHODS

FOXO1, PEPCK, and G6PC mRNA levels were evaluated in 84 subjects: 26 with steatohepatitis, 28 with steatosis alone, 14 with normal liver histology without metabolic alterations, and 16 with hepatitis C virus chronic hepatitis, of whom 8 were with and 8 were without steatosis. Protein expression and regulation of FOXO1 and upstream insulin signaling were analyzed in a subset. RESULTS; Expression of PEPCK was higher in steatohepatitis compared with steatosis alone and normal liver, and it was correlated with the homeostasis model assessment of insulin resistance (HOMA-IR) index. FOXO1 mRNA levels were higher in steatohepatitis, correlated with PEPCK and G6PC mRNA and with HOMA-IR. FOXO1 upregulation was confirmed at protein levels in steatohepatitis and, in the presence of oxidative stress, was associated with decreased Ser(256) phosphorylation, decreased Akt1, and increased Jun NH(2)-terminal kinase-1 activity. Consistently, immunohistochemistry showed increased FOXO1 expression and nuclear localization in steatohepatitis. FOXO1 mRNA levels correlated with nonalcoholic steatohepatitis activity score and were modulated by drugs counteracting hepatic lipogenesis.

CONCLUSIONS

FOXO1 expression and activity are increased in patients with steatohepatitis, and mRNA levels are correlated with hepatic insulin resistance.

Band erosion following gastric banding: how to treat it

BACKGROUND

Intragastric band migration is an unusual but major long-term complication of gastric banding: its frequency ranges from 0.5-3.8% and always requires removal of the band. Different laparoscopic, laparotomic or endoscopic methods are currently used for band removal.

METHODS

571 morbidly obese patients underwent adjustable gastric banding from February 1998 to July 2006. Band erosion occurred in 3 patients (0.52%). In addition, 6 such patients were referred to our Department from other hospitals. To remove the migrated band, in most patients we used an endoscopic approach with a device designed to cut the band: the Gastric Band Cutter (AMI, Agency for Medical Innovation).

RESULTS

In 7 of the 9 patients, we used the gastric band cutter to remove the band endoscopically. It was able to cut the band successfully in all cases except one, where twisting of the cutting wire required conversion from endoscopy to laparoscopy. In another case, the band, after being cut, was locked in the gastric wall and required laparotomic removal. In 2 patients, we had to remove the band surgically - in one case for port-site infection with subphrenic abscess, and in the other case for complete band migration into the jejunum associated with acute pancreatitis, cholelithiasis and choledocholithiasis.

CONCLUSION

The Gastric Band Cutter, when used, was successful in dividing the band in all cases except one, although we could not always complete the procedure endoscopically. Endoscopic removal seems to be the procedure of choice for band erosion, because it allows earlier patient discharge and avoids a surgical operation. It is advisable to perform the endoscopic removal in the operating theater, because of possible complications of the procedure.

Histologic study of tissue reaction to the gastric band: does it contribute to the problem of band erosion?

BACKGROUND

One of the major complications of gastric banding is intragastric migration of the band. The frequency ranges from 0.5% to 3.8%, and removal of the band is always required. We undertook a prospective study with the aim to determine the reasons for this significant complication in bariatric surgery.

METHODS

480 morbidly obese patients underwent adjustable gastric banding in our Surgical Department, from February 1998 to October 2005. 31 of them were reoperated for different surgical problems, at an average time of 39 months after the bariatric procedure. During the reoperation, some fragments of fibro-adipose tissue in close contact with the band were removed. They were examined, focusing on the following parameters: acute and chronic inflammation, fibrosclerosis, and foreign body granulomatous reaction.

RESULTS

Histological assessment showed the presence of acute and chronic inflammation, generally of mild and medium grade; fibrosclerosis was present mostly in a severe form, indicating a biological periprosthesic wall that separates and protects the gastric wall from the band; no cases of foreign body reaction were observed, nor were silicone inclusions found inside the inflammatory cells.

CONCLUSION

The histologic changes of periprosthesic tissue do not appear to account for endoluminal migration of the gastric band. Thus, band erosion could have a closer correlation with other causes, such as infection of the band or intraoperative surgical damage, possibly due to direct mechanical action or to the thermal effect of the electric scalpel.

Stapled transanal rectal resection versus stapled anopexy in the cure of hemorrhoids associated with rectal prolapse. A randomized controlled trial

PURPOSE

A remarkable incidence of failures after stapled axopexy (SA) for hemorrhoids has been recently reported by several papers, with an incomplete resection of the prolapsed tissue, due to the limited volume of the stapler casing as possible cause. The stapled transanal rectal resection (STARR) was demonstrated to successfully cure the association of rectal prolapse and rectocele by using two staplers. The aim of this randomized study was to evaluate the incidence of residual disease after SA and STARR in patients affected by prolapsed hemorrhoids associated with rectal prolapse.

METHODS

Sixty-eight patients were selected on the basis of validated constipation and continence scorings, clinical examination, colonoscopy, anorectal manometry, and defecography and randomized: 34 underwent a SA and 34 a STARR operation. The operated patients were followed-up with clinical examination, visual analog scale for postoperative pain, a satisfaction index, and defecography.

RESULTS

At a mean follow-up of 8.1+/-2.0 and 7.9+/-1.8 months for the SA and STARR groups, respectively, the incidence of residual disease was significantly higher in the first group (29.4 vs 5.9 in the STARR group, p=0.007), while a significantly lower incidence of residual skin-tags was found after STARR (23.5% vs 58.8 after SA, p=0.03). All patients with residual disease showed prolapsed tissue over half the length of the anal dilator at the time of the operation. Operative time and incidence of transient fecal urgency were significantly higher in the STARR group (with p=0.001 and 0.08, respectively), while SA was followed by a significantly higher incidence of poor results at the overall patient satisfaction index (p=0.04). No significant differences were found in hospital stay, operative complications, postoperative pain, time to return to normal activity, continence, and constipation scores. All the defecographic parameters significantly improved after STARR, while SA was followed only by a trend to a reduction of rectal prolapse.

CONCLUSIONS

STARR provides a more complete resection of the prolapsed tissue than SA in patients with association of prolapsed hemorrhoids and rectal prolapse with equal morbidity and significantly lower incidence of residual disease and skin-tags. The anal dilator can be used for selecting the surgical technique.

An unusual complication of gastric banding: recurrent small bowel obstruction caused by the connecting tube

Laparoscopic adjustable gastric banding (LAGB) is a widely performed surgical procedure for morbid obesity. The application of this mini-invasive approach has given the benefits of shorter hospital stay, less postoperative pain and quicker functional recovery. LAGB complications are related either to the access-port, such as port-site infection or tubing disconnection, or to the band, such as band slippage, pouch dilatation, or intragastric migration. We report a case of recurrent small bowel obstruction caused by the connecting tube around a jejunal loop, in a woman who had under-gone LAGB 3 years before. The diagnosis was difficult to establish because the clinical history and examination were non-specific. A 3-dimensional CT scan was needed to explain the cause of the recurrent abdominal pain, and the small bowel loop was freed from the connecting tube at laparoscopy.

Adjustable gastric banding for morbid obesity. Our experience

BACKGROUND

The adjustable gastric banding is considered the most common procedure in Europe for the treatment of morbid obesity. We report our experience with this procedure, that was introduced in our Departments of Surgery since 1993.

METHODS

From December 1993 to December 2004, 684 morbid obese patients (139 males and 545 females) underwent adjustable gastric banding (AGB) in our departments of Surgery. The first 323 patients were operated with perigastric procedure, the following 361 patients with pars flaccida technique. 601 patients were operated with laparoscopic approach, 83 with open approach. The average follow-up is 5 years.

RESULTS

Mean BMI decreased from 42.2 to 34 Kg/m2 five years after the operation, with an EWL of 54 %. The main early complications were: intraoperative gastric perforation (5 patients, 1 of which repaired in laparoscopy); hemorrhage from short gastric vessels (3 patient, repaired in laparotomy). The major late complications were: intragastric band migration (7 patients); irreversible dilatation of the gastric pouch (42 patients, treated surgically with band removal or repositioning).

CONCLUSION

In our experience laparoscopic adjustable gastric banding is a safe and effective procedure, suitable to most patients, and should be considered as the first choice in the surgical treatment of morbid obesity.

Impact of new technologies on the clinical and functional outcome of Altemeier's procedure: a randomized, controlled trial

PURPOSE

A randomized study was performed to assess whether new technologies offer advantages over the conventional technique on the clinical and functional outcome of patients with full-thickness rectal prolapse and fecal incontinence, submitted to Altemeier's procedure with levatorplasty.

METHODS

Between January 1999 and December 2003, 58 patients (55 females; mean age, 70.9 +/- 11.3 years) with full-thickness rectal prolapse were evaluated with continence score, colonoscopy, anorectal manometry, anal electromyography, and sacral reflex latency; 40 of them were selected and randomly assigned to two groups: 20 patients (Group 1; 19 females, 73.4 +/- 10.4 years) were submitted to a conventional operation with monopolar electrocautery and handsewn anastomosis, and 20 (Group 2; 18 females, 71.5 +/- 12.2 years) using harmonic scalpel and circular stapler. Patients were followed up with clinical examination, anorectal manometry, and anal electromyography, with mean follow-up 29.3 +/- 8.5 and 27.5 +/- 9.2 months in Groups 1 and 2, respectively.

RESULTS

Operative time, blood loss, and hospital stay were significantly reduced in Group 2 (P < 0.001), whereas no differences were found in pain score, time to return to normal activity, morbidity, and mortality. Complications were two (10 percent) stenosis in Group 1. Fecal continence score significantly improved in both groups (P < 0.01), whereas anorectal manometry and neurophysiologic data were not significantly modified by the operation. Recurrence rates were 15 and 10 percent in Groups 1 and 2, respectively (P= not significant).

CONCLUSIONS

The clinical and functional long-term results of perineal rectosigmoidectomy with levatorplasty are not influenced by surgical instruments and type of coloanal anastomosis. The clinical relevance of the short-term results in high-risk patients should be specifically investigated.

Tracheal sleeve pneumonectomy: Long-term outcome

Selected primary lung cancers less than 2cm from the carina or invading the tracheo-bronchial angle, formerly considered inoperable, can be amenable to tracheal sleeve pneumonectomy (TSP). Such a delicate technique, can entail remarkable post-operative morbidity and mortality, and only few clinical series are reported. Purpose of this paper is to examine complications and long-term survival of our personal series and those reported in literature. At our academic department from 1983 to December 2004, out of 99 patients with NSCLC less than 2cm from the carina, 35 (35.4%) were deemed inoperable after conventional staging; the remaining 64 underwent surgery. Since 1993 in every patient with lung cancer we perform a thoracoscopic exploration as the first step of the intervention. Unexpected causes of inoperability were found at thoracotomy in nine patients (14.1%) and at thoracoscopy in two other patients. Of the remaining 53 patients, 52 had a right TSP and one a left TSP. Intraoperative mortality was nil. Perioperative mortality was 7.5%. Major complications occurred in 11.3% of the patients. Thirty (56.6) patients are alive and disease-free 23-97 months after surgery; for 18 (33.4%) of these, more than 5 years have elapsed after the operation. TSP is the only concrete option for treating lung cancer originating less than 2 cm from the carina. The review of our experience and of other reported series suggests that, with careful selection of patients and meticulous surgical technique, operative mortality and complications are acceptable. Long-term survival and prognosis are encouraging.

Prevention of Pouch Dilatation after Laparoscopic Adjustable Gastric Banding

BACKGROUND

The major long-term complication of laparoscopic adjustable gastric banding (LAGB) is dilatation of the gastric pouch, that is reported with a frequency ranging from 1 to 25%, and often requires removal of the band. In addition to the usual recommendations of bariatric surgery centers and dietetic advice to prevent this complication, over the last 4 years we introduced a technical modification of the procedure.

METHODS

From Nov 1993 to Dec 2004, 684 morbidly obese patients underwent adjustable gastric banding, 83 patients by open surgery and 601 patients by laparoscopy. The first 323 patients (group A) were operated by the perigastric approach, and 57 patients (group B) were operated by the pars flaccida approach. Since Dec 2000, 304 patients (group C) were operated with a modified pars flaccida technique, which consisted in suturing the gastric lesser curvature below the band with one or two stitches to the right phrenic crus to secure the band in place.

RESULTS

In group A, the most important late complication was irreversible dilatation of the gastric pouch, which occurred in 35 patients (10.8%), and required removal of the band in 30 cases and replacement in 5. In group B, there were 3 pouch dilatations (5.2%). In group C, only 4 dilatations occurred (1.31%), which required 3 band removals and 1 band replacement.

CONCLUSION

Dilatation of the gastric pouch appears to be dramatically reduced by our minor technical modification of band placement.

Multimedia article. Video-assisted thoracoscopic major pulmonary resections: technical aspects, personal series of 259 patients, and review of the literature, part 2

BACKGROUND

Although more than 10 years have passed since the first video-assisted thoracoscopic lobectomies, these procedures have not gained widespread acceptance. We discuss the technical aspects and major problems associated with these operations, focusing on their present status and future perspectives. The results of our clinical series are presented and the relevant literature is reviewed.

METHODS

From October 1991 to June 2003, 344 patients were submitted to surgery for an intended video major pulmonary resection.

RESULTS

Of the 344 patients, seven (2.0%) were deemed inoperable at video exploration; 78 (23.1%) required conversion, either for technical reasons (n = 3), anatomical problems (n = 49), oncological conditions (n = 20), or intraoperative complications (n = 6). We carried out 253 video-assisted lobectomies and six pneumonectomies (209 for primary lung tumor, 43 for benign disease, and seven for metastases). There were no intraoperative deaths. Two patients died postoperatively. Complications occurred in 20 patients (7.7%). Global survival at 3 and 5 years was 83.24% (+/-6.9) and 68.87% (+/-9.7), respectively. Patients with T1 N0 cancer had a better survival rate at 3 and 5 years (87.13 +/- 8.3% and 75.12 +/- 12.2%) than those with T2 N0 cancer (78.49 +/- 11.2% and 61.2 +/- 15%).

CONCLUSIONS

Based on our experience and a review of the literature, we conclude that video-assisted thoracoscopic lobectomies offer less postoperative pain, a more rapid recovery, and better cosmetic results than their conventional counterpart. The results at 3- and 5-year follow-up for cancer are attractive. However, because no randomized study has yet proved these benefits definitively, further studies are still needed.

Video-assisted thoracoscopic major pulmonary resections: technical aspects, personal series of 259 patients, and review of the literature

BACKGROUND

Although more than 10 years have passed since the first video-assisted thoracoscopic lobectomies, these procedures have not gained widespread acceptance. We discuss the technical aspects and major problems associated with these operations, focusing on their present status and future perspectives. The results of our clinical series are presented and the relevant literature is reviewed.

METHODS

From October 1991 to June 2003, 344 patients were submitted to surgery for an intended video major pulmonary resection.

RESULTS

Of the 344 patients, seven (2.0%) were deemed inoperable at video exploration; 78 (23.1%) required conversion, either for technical reasons (n = 3), anatomical problems (n = 49), oncological conditions (n = 20), or intraoperative complications (n = 6). We carried out 253 video-assisted lobectomies and six pneumonectomies (209 for primary lung tumor, 43 for benign disease, and seven for metastases). There were no intraoperative deaths. Two patients died postoperatively. Complications occurred in 20 patients (7.7%). Global survival at 3 and 5 years was 83.24% (+/-6.9) and 68.87% (+/-9.7), respectively. Patients with T1 N0 cancer had a better survival rate at 3 and 5 years (87.13 +/- 8.3% and 75.12 +/- 12.2%) than those with T2 N0 cancer (78.49 +/- 11.2% and 61.2 +/- 15%).

CONCLUSIONS

Based on our experience and a review of the literature, we conclude that video-assisted thoracoscopic lobectomies offer less postoperative pain, a more rapid recovery, and better cosmetic results than their conventional counterpart. The results at 3- and 5-year follow-up for cancer are attractive. However, because no randomized study has yet proved these benefits definitively, further studies are still needed.

Long-term Survival After Videothoracoscopic Lobectomy for Stage I Lung Cancer

STUDY OBJECTIVES

The aim of this study was to evaluate our personal experience and survival curves after video-assisted thoracic surgery (VATS) lobectomies for stage I lung cancer, in comparison with the results reported in existing literature.

DESIGN

Retrospective analysis of our experience and an overview of literature.

SETTING

Department of Surgery, San Giuseppe Hospital, University of Milan.

PATIENTS

From October 1991 to December 2001, of 257 patients with clinical stage I lung cancer, 193 patients underwent VATS lobectomy, 7 patients were declared inoperable at thoracoscopic exploration, and 57 patients were converted (18 patients for oncologic reasons and 39 patients for technical reasons).

RESULTS

We observed no intraoperative mortality and no recurrence. Survival data were analyzed with the Kaplan-Meier method along with a log-rank test for statistical significance. The global survival rates at 3 years and 5 years were 77.7% and 63.64%, respectively. T1N0 patients had a better survival curve at 3 years and 5 years (83.50% and 70.21%, respectively) compared to T2N0 patients (71.13% and 56.12%). Patients < 70 years of age had better 3-year and 5-year survival rates (82.37% and 73.32%, respectively) than those > 70 years of age (57.49% and 37.09%). This difference was statistically significant (p < 0.01).

CONCLUSIONS

Our results after the VATS approach match the "best" results reported in literature following conventional surgery. Minimally invasive surgery seems to imply reduced tissue damage and decreased impairment of immunologic function. VATS lobectomy permits radical oncology as accurately as lobectomy by thoracotomy, provided that long-established standards are respected. In spite of technical difficulties, it could therefore become a valid alternative in treating stage I lung cancer.

New trends in the surgical treatment of outlet obstruction: clinical and functional results of two novel transanal stapled techniques from a randomised controlled trial

BACKGROUND AND AIMS

A randomised trial was undertaken to compare the clinical and functional results of two novel transanal stapled techniques in patients with outlet obstruction syndrome.

MATERIALS AND METHODS

Ninety-six females with outlet obstruction were treated with medical therapy and biofeedback for 2 months; 67 non-responders were evaluated by the Constipation Scoring and Continence Grading Systems, clinical examination, endoscopy, dynamic defecography, anorectal manometry, transanal ultrasound and anal EMG, and 50 of them, all affected with descending perineum, intussusception and rectocele, were randomly assigned to two groups and operated on: 25 patients (mean age 53.2+/-15.3 years) underwent a single Stapled Trans-Anal Prolapsectomy, associated with Perineal Levatorplasty (STAPL Group), and the other 25 (mean 54.6+/-14.2 years) underwent a double Stapled Trans-Anal Rectal Resection (STARR Group). Patients were followed-up for a mean period of 23.4+/-5.1 months in STAPL Group and 22.3+/-4.8 in STARR Group.

RESULTS

STARR Group showed a significantly (p<0.0001) lower pattern of postoperative pain and a greater decrease (P=0.0117) of the rectal sensitivity threshold volume; otherwise, no differences were found in operative time, hospital stay, or time of inability to work. Complications included delayed healing of the perineal wound (ten), dyspareunia (five), urinary retention (two) and stenosis (one) in STAPL Group, and urge to defecate (four), transitory incontinence to flatus (two), urinary retention (two), bleeding (one) and stenosis (one) in STARR Group. All constipation symptoms significantly improved without worsening of anal continence and with excellent/good outcome at 20 months in 76 and 88% of patients of STAPL Group and STARR Group, respectively. Seven patients of STAPL Group had a little residual rectocele, while both intussusception and rectocele were corrected in all patients of STARR Group. Neither operation modified anal pressures or caused lesions of anal sphincters.

CONCLUSIONS

Both techniques are safe and effective in the treatment of outlet obstruction; nevertheless, the double Stapled Trans-Anal Rectal Resection seems to be preferable due to less pain, absence of dyspareunia, reduced rectal sensitivity threshold volume and absence of residual rectocele at defecography.

Non-small cell lung cancer with chest wall invasion: evolution of surgical treatment and prognosis in the last 3 decades

STUDY OBJECTIVES

The treatment of patients with non-small cell lung cancer (NSCLC) that is invading the chest wall is still debated. We aim to illustrate the improvements in treatment results that have occurred over last decade.

DESIGN

Retrospective analysis of our experience and an overview of the literature.

SETTING

Department of Surgery, San Giuseppe Hospital, University of Milan.

PATIENTS

From January 1970 to December 1999, of 2,738 patients with NSCLC, we operated on 146 patients (5.4%) with chest wall invasion by NSCLC. Superior sulcus tumors and tumors invading the diaphragm or mediastinum were excluded. We reclassified all cases according to the current TNM classification.

RESULTS

We registered one postoperative death (0.69%) and five major complications (3.4%). From 1970 to 1979, of 32 patients, 10 underwent an exploratory thoracotomy (ET) and 22 underwent a radical resection (stage IIB disease, 17 patients; stage IIIA disease, 5 patients). The 5-year survival rate was 22.7% (25% for stage IIB disease). From 1980 to 1989, of 67 patients, 11 underwent an ET and 56 underwent a radical resection (stage IIB disease, 34 patients; stage IIIA disease, 12 patients; stage IIIB disease, 5 patients; and stage IV disease, 5 patients). The survival rate following radical resection was 14.1%, ranging between 23.5% for patients with stage IIB disease and 0% (3 years, 14%) for those with stage IIIA disease. From 1990 to 1999, of 47 patients, 2 underwent an ET, 2 underwent an exploratory thoracoscopy, and 43 underwent a radical resection (stage IIB disease, 23 patients; stage IIIA disease, 20 patients). The survival rate was 42.7% (stage IIB disease, 78.5%; stage IIIA disease, 7.2%).

CONCLUSIONS

Considering the low morbidity, mortality, and significant improvement in survival during the last decade, we advocate the performance of radical en bloc resection for the treatment of chest wall invasive NSCLC.

Thoracoscopy and transplantation: a new attractive tool

BACKGROUND

Transplanted patients on immunosuppressive treatment have an increased risk of infections or neoplasms. Transplantation candidates with infection or a suspected malignancy are excluded from transplantation. In patients already transplanted, thoracoscopy can resolve complications or treat the pulmonary pathology without compromising the precarious existing reactive equilibrium. These patients require an approach that is as least traumatic as possible.

METHODS

From September 1991 to December 2000, of 2068 videothoracoscopic procedures carried out at our hospital, 2 were in patients who had undergone transplantation and 3 in candidates for kidney, liver, and bone marrow transplantation. Starting from our personal experience in videothoracoscopy as a diagnostic and therapeutic approach, the possibilities of the method in the field of transplantation are reported by a review of the literature carried out by consulting the reference systems of the most important data banks.

CONCLUSIONS

In our experience, videothoracoscopy had a major impact on the management of candidates for transplant, because it allowed us to rule out or treat conditions that would have determined exclusion from a transplant program. In transplanted patients, videothoracoscopy allows a correct diagnosis and treatment with minimal trauma.

Complications of tracheal sleeve pneumonectomy: personal experience and overview of the literature

OBJECTIVES

Tracheal sleeve pneumonectomy, although technically demanding, is considered the choice for tracheobronchial angle cancers. Complications in our 49 tracheal sleeve pneumonectomies are reviewed. Results, complications, and technical aspects are critically discussed. Although series in the literature differ in selection of patients and surgical techniques and extend over long periods, we attempt to compare our experience with results from the literature.

METHODS

From 1983 to September 1999, 60 patients eligible for tracheal sleeve pneumonectomy after conventional staging underwent operation. A Sybilla Fome-Cuf ventilation tube (Bivona, Inc, Gary, Ind) was used starting in 1987 to facilitate anastomosis. Since 1993, all patients have undergone video-assisted thoracoscopy immediately before the operation.

RESULTS

There were 11 (18.3%) exploratory thoracotomies, 48 right tracheal sleeve pneumonectomies, and 1 left tracheal sleeve pneumonectomy. Among the tracheal sleeve pneumonectomies, we recorded 4 (8.2%) perioperative deaths (myocardial infarction, n = 1; heart failure, n = 1; pulmonary edema, n = 1; gastric ulcer hemorrhage, n = 1; and anastomotic fistula in a patient who received high-dose radiation before the operation, n = 1). We observed 5 (10.2%) complications (lung edema, n = 1; transitory recurrent nerve palsy, n = 2; empyema without fistula cured conservatively, n = 1; and pneumonia, n = 1). Anastomotic stenosis did not occur. Twenty-six (53%) patients are alive 14 to 87 months postoperatively, 12 (24.5%) of these more than 5 years postoperatively. Five (10.2%) died of mediastinal recurrence at 6 and 54 months. Two others (4.1%) died in road accidents.

CONCLUSIONS

Tracheal sleeve pneumonectomy is a demanding operation with a high risk of complications. Analysis of literature and personal experience shows that complications can be greatly reduced through accurate selection of patients, precise technique, and optimal postoperative care. Long-term survival equals that obtained after standard pneumonectomy.

Videothoracoscopic approach to primary mediastinal pathology

STUDY OBJECTIVES

Personal results and validity of videothoracoscopic (VTS) approach to primary mediastinal diseases are analyzed.

DESIGN

Retrospective review of personal experience.

SETTING

Department of Surgery, San Giuseppe Hospital, University of Milano, Italy.

PATIENTS

From September 1991 to January 1999, of a personal series of 1,653 VTS procedures, 118 regarded primary mediastinal diseases. In 47 cases, diagnostic videothoracoscopy was performed to obtain large biopsy specimens or to carry out accurate staging; in 71 cases, full resection was anticipated.

INTERVENTIONS

The patient, intubated with a double-lumen Carlen's tube and in the lateral decubitus position, underwent videothoracoscopy. Two ports and a small anterior utility thoracotomy were completed. Thorough exploration of the mediastinum and, if possible, complete resection of the lesion were accomplished.

MEASUREMENTS AND RESULTS

Videothoracoscopy yielded adequate diagnosis or staging in all patients operated on for diagnostic purposes. Of 71 patients operated on with resective intent, 66 had complete thoracoscopic resection (22 stage-I thymomas, 4 thymic cysts, 21 myasthenia gravis associated with thymic hyperplasia, 19 miscellaneous tumors). Conversion was required in five cases, mostly for invasion of mediastinal structures. Complications included the following: one patient developed intraoperative bleeding controlled endoscopically, two patients experienced postoperative bleeding requiring re-thoracoscopy, and one patient had postoperative pneumonia requiring assisted ventilation. One recurrence of malignant thymoma occurred 4 years postoperatively.

CONCLUSIONS

Videothoracoscopy can attain a leading role in obtaining large samples in lymphatic mediastinal diseases. Dysembriomas, schwannomas, simple cysts, and similar lesions can benefit from VTS removal. Total thymectomy for myasthenia gravis associated with thymic hyperplasia can be performed thoracoscopically. Further data and more extensive experience are needed.

Techniques of pneumonectomy. Video-assisted thoracic surgery pneumonectomy

Thoracoscopic major pulmonary resections such as lobectomies or pneumonectomies are the most difficult operations that can be attempted thoracoscopically, and still have limited routine application in thoracic surgical practice. The precise indications for thoracoscopic pneumonectomy are very rare and have not yet been defined precisely; we limited the procedure only to double tumors, small tumors infiltrating the fissure, and small tumors at the secondary carina not amenable to a bronchoplasty procedure. Although the technique still has very limited applications, the advantages include reduced surgical trauma and consequent minimal postoperative pain, a shortened hospital stay, and a rapid resumption of normal activities which ultimately reduces costs. Wider acceptance, larger series, and a more extensive follow-up will assess the role of thoracoscopic anatomical lung resection in modern thoracic surgical practice.

Video-assisted thoracoscopic surgery (VATS) major pulmonary resections: the Italian experience

Videoendoscopic lobectomies or pneumonectomies are infrequently performed, mostly because of technical difficulties, concern for intraoperative accidents, and radicality in case of malignancy. The work diffusely describes technical details and a personal experience of videothoracoscopic major pulmonary resections (MPRs). All patients are first explored thoracoscopically. The procedure can then be completed thoracoscopically or converted. Videothoracoscopic exploration was performed in 211 candidates to MPR. Six patients' cases became nonresectable owing to pleural carcinomatosis or mediastinal infiltration, 171 patients completed a thoracoscopic MPR (165 lobectomies and 6 pneumonectomies), and 34 required conversion for technical (20) or oncological (10) reasons. Video MPRs were performed for benign disease (24), for lung metastases (5) and for preoperatively staged T1N0 or T2N0 primary lung cancer (142). No perioperative mortality was recorded. In 154 patients (90%), postoperative course was uneventful. One patient died after 33 days because of contralateral pneumonia; 15 elderly patients had prolonged air leaks. One patient developed partial dehiscence of the bronchial stump (healed conservatively) after a severe respiratory insufficiency on his third postoperative day had required mechanical ventilation. Even though video MPR can present remarkable difficulties, its undeniable advantages will benefit from further improvement of instrumentation. In case of tumors, larger series and longer follow-up will allow evaluation of long-term survival and local recurrence.

Endoscopic treatment of bronchopleural fistulas

BACKGROUND

Bronchial fistula is one of the most serious complications of pulmonary resection.

METHODS

We present an endoscopic treatment that consists of multiple submucosal injections of polidocanol-hydroxypoliethoxidodecane (Aethoxysklerol Kreussler) on the margins of the fistula using an endoscopic needle inserted through a flexible bronchoscope.

RESULTS

From 1984 to 1995, 35 consecutive nonselected patients with a postresectional bronchopleural fistula were treated. All 23 partial postpneumonectomy or postlobectomy bronchopleural fistulas, ranging from 2 to 10 mm in diameter, healed completely. This did not occur in the 12 total bronchial dehiscences. No complications occurred due to the injection of the drug.

CONCLUSIONS

In our opinion this treatment can be considered a valid therapeutic approach, as it is simple, safe, scarcely traumatic, and inexpensive, particularly considering that, in patients in stable condition, it can be performed as an outpatient treatment.

Experimental oesophagogastric anastomosis: preliminary report of a new compression device that also fragments

Fifteen Beagle dogs underwent oesophagogastric anastomosis with a new device which enables a 'sutureless' compression anastomosis. The device fragmented and was passed in bits anally without causing obstruction. Immediate bursting pressure, tested in five dogs, was between 175 and 190 mmHg. The anastomoses of the remaining dogs were examined macroscopically and microscopically from day 6 to day 30. Healing was excellent with good muscular apposition and minimal residual inflammation.

Videothoracoscopic staging and treatment of lung cancer

Videothoracoscopy, routinely performed as the initial step of an operation, opens interesting opportunities for both the operative staging and treatment of lung cancer. Videosurgical maneuvers ensure thorough exploration of the cavity, thus avoiding unnecessary exploratory thoracotomies, confirming resectability of the lesion by open or, in selected cases, by a direct video-assisted approach. We report our experience of 155 patients submitted to videothoracoscopic operative staging between October 1991 and January 1994. Videothoracoscopic operative staging showed unresectability in 13 patients (8.3%) due to preoperatively unexpected (10 patients) or suspected conditions (3 patients). The remaining 142 patients were divided by staging of the lesion and general conditions into three groups. Group A consisted of 13 elderly patients with small peripheral tumor who could not tolerate lobectomy and who underwent thoracoscopic wedge resection. Group B consisted of 63 patients with peripheral clinical T1 N0 or T2 N0 tumor. Fifty-two lobectomies and 4 pneumonectomies were carried out thoracoscopically. Seven conversions to thoracotomy were necessary due to technical problems. The postoperative course was uneventful in 51, 5 had prolonged air leakage, and a bronchial fistula developed in 1 because of positive-pressure postoperative ventilation. Group C consisted of 66 patients with stage II or IIIa neoplasm. Thoracotomy after thoracoscopy proved unresectability in 4, whereas 62 were submitted to a radical pulmonary resection. In the literature the incidence of exploratory thoracotomies for conditions missed by preoperative staging still remains high. After adoption of videothoracoscopic operative staging we reported a 2.6% exploratory thoracotomy rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections: a prospective, controlled, randomized clinical trial

BACKGROUND

A prospective, randomized controlled clinical trial was conducted in 33 Italian surgical departments with the aim of evaluating the efficacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections.

METHODS

Between July 1990 and May 1992, 278 patients were enrolled in the study. Fifty-four dropped out because of unresectable disease and six were excluded because of protocol violation; the remaining 218 were randomly assigned to the octreotide group (n = 111) or to the placebo group (n = 107). There were 131 men and 87 women with a mean age of 58.2 +/- 11.7 yrs. Pancreaticoduodenectomy was the most common operation performed (n = 143), sixty-four percent of patients had a pancreatic or periampullary cancer; chronic pancreatitis accounted for 8.2% of cases.

RESULTS

Mortality rate was 6.9%. A pancreatic fistula occurred in 31 patients (14.2%), 9% in the octreotide group and 19.6% in the placebo group (p < 0.05). Morbidity rate was significantly lower in the octreotide (21.6%) than in the placebo group (36.4%) (p < 0.05). When specific pancreatic complications were grouped together and evaluated, they occurred less frequently in the treated (15.3%) than in the placebo group (29.9%) (p < 0.05).

CONCLUSIONS

Octreotide was able to reduce significantly the incidence of pancreatic fistula after elective pancreatic resections.

Videothoracoscopic excision of mediastinal masses: indications and technique

Mediastinal masses are generally excised through wide thoracotomies or median sternotomies. These lesions are often benign, usually asymptomatic, discovered incidentally, and relatively easy to resect. For these reasons, a minimally invasive approach is appropriate. Videothoracoscopy allows an optimal exploration of the pleural cavity and a panoramic view of the mass. Dissection is usually easy to perform, and the mass can be extracted from the thorax through a trocar incision or through a limited "utility thoracotomy." To avoid possible tumor seeding, the mass is inserted in a plastic bag before extraction. From September 1991 to January 30, 1994, 20 mediastinal masses (6 thymomas, 2 thymic cysts, 1 hyperplastic thymus, 1 fibrous tumor of the mediastinum, 2 pleuropericardial cysts, 2 thoracic teratomas, 2 large thoracic lipomas, 3 neurogenic tumors, and 1 bronchogenic cyst) were removed through such a minimally invasive approach. Eighteen patients had an uneventful postoperative course. Two patients hemorrhaged in the immediate postoperative period, and repeat thoracoscopy was done. In 1 patient, electrocoagulation of a bleeding intercostal artery controlled the hemorrhage. In the other, the source of bleeding could not be found, and removal of the clots and irrigation of the cavity stopped the hemorrhage. Further data and long-term follow-up are necessary, but videothoracoscopy offers a new, less invasive approach for the management of noninvasive mediastinal masses.

Major pulmonary resections: pneumonectomies and lobectomies

We report on our experience in 20 patients who underwent major thoracoscopic pulmonary resections between October 1991 and November 1992. These consist of 2 left pneumonectomies, 17 lobectomies, and 1 segmentectomy. The indications were strictly limited to benign pulmonary diseases and stage I (TNM) primary lung cancer. A hilar lymphadenectomy was performed in all cases of malignancy. Our surgical technique is described. Our findings demonstrate the feasibility of performing major video-assisted thoracoscopic pulmonary resections, even though the definite role of this procedure in the management of lung cancer must still be defined.

Videothoracoscopic excision of a mediastinal thymoma

The authors have applied the advances in optics, endotelevision monitoring, and instrumentation that have led to the development of videoendoscopic abdominal surgery to performing major excisional procedures in the thorax. A videothoracoscopic technique for the removal of a mediastinal thymoma is described. The procedure was done on a 24-year-old woman suffering from a benign lymphoepithelial thymoma of the mediastinum. The mediastinal mass was mobilized under videolaparoscopic guidance and extracted from the thorax through a small (4 cm) inframammary incision. The postoperative course was uneventful, and the patient experienced minimal postoperative pain. She was discharged on the 3rd postoperative day with excellent functional and cosmetic results and resumed normal activity 4 days later.

[Preoperative localization and anchoring of pulmonary nodules under computed tomography guidance]

Videoendoscopic thoracic surgery is often employed to remove peripheral lung nodules. Since manual palpation is excluded, the authors obviate the difficulty of intraoperative nodule localization by employing a thin snap open mandrel under CT to guidance localize, fix and anchor the nodule. Traction can be exerted on the device allowing for rapid nodule identification and facilitating wedge resection removal. This technical innovation, as yet applied only to a limited number of cases, widens the indications of videothoracoscopic surgery and appears complication-free.

Videoendoscopic pulmonary lobectomy for cancer

A videothoracoscopic right lower pulmonary lobectomy is reported. The excision was done in a 71-year-old man suffering from an adenocarcinoma of the right lower lobe, with an apparent absence of lymphnodal and systemic metastasis. The procedure has been performed using four 10-mm cannulas and a minimal inframammary thoracotomy (4 cm) by inserting a chip camera linked to the thoracoscope and connected to external monitors. The lobar hilar structures were dissected and then sutured-divided with Endo-GIA R shots. The specimen was extracted through the minimal thoracotomy. The postoperative course was uneventful with minimal postoperative pain, and the patient was discharged after complete surgical recovery with excellent functional and cosmetic results. This procedure in selected patients is a new and promising possibility in chest videoendoscopic surgery.