Which is the correlation between carcinoid tumor and Laparoscopic Sleeve Gastrectomy? A case series and literature review.

INTRODUCTION: Gastric Carcinoid Tumors (GCT) are very rare in general population, but some studies evidenced a higher incidence among bariatric surgery patients. Laparoscopic Sleeve Gastrectomy (LSG) is a widely accepted procedure for the surgical treatment of morbid obesity. LSG acts both in reducing food intake and interfering with hormonal balance in the gut-brain axis. In these patients, incidental GCT diagnosis can occur both during pre-bariatric surgery investigation and during post-operative follow-up. METHODS: We retrospectively analyzed the database of obesity patients submitted to LSG in two different centers to find out incidence of GCT in patients treated by surgery from May 2013 to March 2018. RESULTS: From the 560 obese consecutive patients underwent LSG, we recorded two cases of patients with GCT (0.36%): the case 1 was a patient who had a pre-operative diagnosis of GTC receiving a curative LSG which totally included the carcinoid in the resected portion; the case 2 was a patient that received a curative endoscopic resection 42 months after LSG. DISCUSSION: the predisposing factors that can correlate GCT with obesity and LSG and in particular the hormonal changes have been discussed. We illustrated our experience about the management of these tumors in obese patients. CONCLUSION: there are neither certain data which evidence a correlation between obesity and GCT, nor data to support the hypothesis of a higher incidence of GCT after bariatric surgery. Based on our experience in obese patients the finding of GCT in the pre-operatory phase is not an absolute contraindication for bariatric surgery.

High Resected Gastric Volume and poorly controlled DM2 in laparoscopic sleeve gastrectomy.

BACKGROUND: Our aim is to evaluate the effects of High Resected Gastric Volume(HRGV) on poorly Type 2 Diabetes Mellitus(DM2) after Laparoscopic Sleeve Gastrectomy(LSG). METHODS: 256 patients were divided into two groups according to the RGV: < 1500 mL(Group A: 131 pts) and > 1500 mL(Group B: 147 pts). % excess body mass index loss (%EBMIL), Fasting Blood Glucose (FBG), HbA1c, C peptide were assessed before surgery and at the 3rd day, 6th,12th,24th,36th month after LSG. RESULTS: A significant difference in %EBMIL between the two groups at 24 and 36 months was found. RGV was not significantly associated with DM2 in the multivariate logistic regression. FBG levels showed no differences between the two groups. A significant decrease of Hb1Ac at 6 and 12 months was found in group B. The C-peptide level showed a significant reduction at 6 and 12 months in group B. CONCLUSION: The HRGV may play a role in the regulation of the glucose metabolism in the first year after LSG without influence in poorly DM2 control. Further studies are needed to confirm these findings.

Resolution of type 2 diabetes after sleeve gastrectomy: a 2-step hypothesis.

BACKGROUND: Weight loss (WL) and altered gut hormonal levels are involved in glucose homeostasis after laparoscopic sleeve gastrectomy (LSG). OBJECTIVES: The aim of this study was to evaluate the time-related effects of WL, ghrelin, and glucacon-like peptide-1 (GLP-1) plasma concentrations on type 2 diabetes resolution after LSG. SETTING: University hospital, Italy. METHODS: Ninety-one patients who underwent LSG were investigated. Insulin secretion (insulinogenic index [IGI]), insulin resistance, plasma glucose level and percentage glycated hemoglobin using the oral glucose tolerance test were assessed before surgery, on postoperative day 3, and then at 6, 12, 24, and 36 months after LSG. At the same time points, WL, ghrelin, and GLP-1 levels were determined. RESULTS: During follow-up, the resolution rate of type 2 diabetes was 9.4%, 42.3%, 71.8%, 81.2%, and 91.8%, respectively. Ghrelin plasma concentrations decreased significantly after LSG (271.5 ± 24.5 pg/mL versus 122.4 ± 23.4 pg/mL, P = .04). GLP-1 plasma concentrations increased significantly after LSG (1.7 ± 2.6 pg/mL versus 2.5 ± 3.4 pg/mL, P = .04). The percentage of excess weight loss and IGI presented a positive linear correlation (r) at all follow-up time points with a strong positive correlation at 12 and 24 months. A strong negative correlation between ghrelin and IGI was recorded during the first 3 days after LSG (r = -.9). GLP-1 and IGI presented a strong positive correlation at day 3 and 6 months (i.e., .8 and .8, respectively). CONCLUSION: LSG may affect glucose homeostasis by 2 different time-related modes: a first step in which the hormonal changes play a predominant role in glucose homeostasis and a second step in which the percentage excess weight loss determines the metabolic results.

The effect of sleeve gastrectomy on GLP-1 secretion and gastric emptying: a prospective study.

BACKGROUND: Rapid gastric emptying has been proposed to justify the increase in glucagon-like polypeptide-1 (GLP-1) after laparoscopic sleeve gastrectomy (LSG). OBJECTIVES: To assess gastric emptying changes after LSG and their relationship with GLP-1 secretion. SETTING: San Salvatore Hospital general surgery unit, University of L'Aquila, Italy. METHODS: 52 patients underwent gastric emptying scintigraphy for liquid and solid foods, before and 3 months after LSG. Twenty-six patients were in the liquid group (L group) and the remaining in the solid group (S group). We evaluated the half time of gastric emptying (T1/2) and percentage of gastric retention (%GR) at 15, 30, and 60 minutes for liquids and at 30, 60, 90, and 120 minutes for solids. GLP-1 plasma concentrations were measured in each group before and after LSG and related to %GR. Statistical analysis was performed by Χ2 test and Pearson correlation(r). RESULTS: After surgery, T1/2 was significantly accelerated: 15.2±13 min and 33.5±18 min in the L group and S group, respectively (P<.05). In both groups, GLP-1 plasma concentrations were increased at each blood sampling time: 2.91±2.9 pg/mL, 3.06±3.1 pg/mL and 3.21±2.6 pg/mL at 15, 30, and 60 minutes, respectively, (P<.05) for L group and 2.72±1.5 pg/mL, 2.89±2.1 pg/mL, 2.93±1.8 pg/mL, and 2.95±1.9 pg/mL at 30, 60, 90, and 120 minutes, respectively, (P< .05) for the S group. After LSG, GLP-1 and %GR presented a negative linear correlation (r) at each blood sampling time in both groups. CONCLUSION: The rapid gastric emptying 3 months after LSG upregulates the production of GLP-1 in the distal bowel. Further studies are needed to confirm these findings.

Effect of Resected Gastric Volume on Ghrelin and GLP-1 Plasma Levels: a Prospective Study.

BACKGROUND: The correlation between resected gastric volume (RGV) and neuro-humoral changes (ghrelin and GLP-1) after laparoscopic sleeve gastrectomy (LSG) and their effects on type 2 diabetes mellitus (T2DM) has been evaluated. MATERIALS: Ninety-eight patients were divided in two groups: RGV <1200 mL (group A: 53 pts) and RGV >1200 mL (group B: 45 pts). Insulin secretion (insulin area under the curve (AUC)), insulinogenic index (IGI) and insulin-resistance (homeostasis model assessment, HOMAIR) were assessed before and after surgery (at the 3rd day and 6, 12 and 24 months after LSG) using the oral glucose tolerance test (OGTT). At the same time, ghrelin and GLP-1 levels were determined. RESULTS: A significant difference in T2DM resolution rate was observed after 6, 12 and 24 months in favour of RGV >1200 mL. Group B performed better than group A at the 3rd day and at the 6th, 12th and 24th months with regard to AUC, IGI and HOMAIR. In both groups, OGTT resulted in decreased ghrelin values and a significant increase in GLP-1 values for group B at the 3rd day and at the 6th and 12th months with no difference at the 24th month. CONCLUSION: Ghrelin and GLP-1 changes play a role in the regulation of glucose metabolism during the 1st year after LSG. RGV influences ghrelin and GLP-1 plasma levels after LSG, with a significant improvement in the T2DM control.

Twelve years of gastric GIST A retrospective study of laparoscopic and open approach.

PURPOSE: The authors wanted to evaluate the outcome of laparoscopic and open resection for gastric GISTs, in the long and short run with a retrospective study based on 63 consecutive patients. METHODS: Two surgical groups were compared according to age, sex, ASA group and Surgical procedure: a laparoscopic resection was performed on 30 patients (47,7%) while the open approach was preferred for 33 patients (52,3%). Duration of surgery, blood loss, positive resection margins, postoperative morbidity, postoperative ileus, hospital stay, tumor's mean dimensions, degree of malignancy and recurrences rate and 5-years mortality were compared in subgroups. RESULTS: Significant differences between Open Gastrectomy group and Laparoscopic Gastrectomy group were found in blood loss 425 ml (180-610) vs 137 ml (110-320), postoperative ileus 4,1D (3-6) vs 2,3D (1-7), hospital stay 15D (8-25) vs 10D (8-17), neoplasia mean dimensions in patients who underwent total gastrectomy ( 7,1±0,9 cm vs 5,3±0,5 cm) and atypical gastrectomy (4,3±0,8 cm vs 2,2±0,3 cm), high degree of malignancy in patients who underwent subtotal gastrectomy (4 vs 0 pz) and 5-years mortality in patients who underwent total gastrectomy (36.6% vs 12.5%). CONCLUSIONS: Poor blood loss, shorter postoperative ileus and shorter hospital stay in the LG group show that laparoscopy can be performed safely and efficiently in gastric GISTs.

Ultrasonic versus standard electric dissection in laparoscopic cholecystectomy in patients with acute calculous cholecystitis, complicated by peritonitis: influence on the postoperative systemic inflammation and immune response. A prospective randomized study.

BACKGROUND: Ultrasonic surgery can dissect structures and divide vessels by the effect produced by vibrations in the tissues. It is believed to be less traumatic than the more commonly used monopolar electrosurgery (ELC). Laparoscopic techniques are being used increasingly in surgical conditions complicated by peritonitis. This randomized study compares the acute inflammatory and systemic immune response after laparoscopic cholecystectomy in patients with acute calculous cholecystitis, complicated by peritonitis, performed using either ultrasonic energy or ELC. PATIENTS AND METHODS: Forty-three patients, scheduled for laparoscopic cholecystectomy, were randomly assigned to treatment using either an ultrasonic device (UC) (n=22 patients) or ELC (n=21 patients). Bacteremia, endotoxemia, white blood cells, the peripheral lymphocyte subpopulation, human leukocyte antigen-DR (HLA-DR), neutrophil-elastase, interleukin-6 and -1, and C-reactive protein (CRP) were investigated. RESULTS: Significantly higher concentration of systemic endotoxin, neutrophil, neutrophil-elastase, interleukin-6 and -1, and CRP were detected intraoperatively and/or postoperatively in the ELC group of patients in comparison with the UC group (P<.05). A statistically significant change in HLA-DR expression was recorded on postoperative Day 1 as a reduction of this antigen expressed on the monocyte surface in patients from the ELC group; no changes were noted in UC patients (P<.05). We recorded 4 patients (22.2%) who developed an intraabdominal abscess in the ELC group and 1 (4%) in the UC group (P<.05). CONCLUSIONS: Laparoscopic cholecystectomy after biliary peritonitis, conducted by ELC, increased the incidence of bacteremia and systemic inflammation compared with the UC group. Early enhanced postoperative systemic inflammation may cause lower transient immunologic defense in the ELC group, leading to enhanced sepsis.

New harmonic scalpel versus conventional hemostasis in right colon surgery: a prospective randomized controlled clinical trial.

BACKGROUND: The Harmonic Scalpel (HS) is a device that uses vibrations to coagulate and cut tissues simultaneously. Its advantages are represented by minimal lateral thermal tissue damage, less smoke formation, no neuromuscular stimulation and no transmission of electricity to the patient. METHODS: A total of 211 consecutive patients (113 men, 98 women; mean age 64 years) undergoing hemicolectomy for cancer of the right colon were divided into two groups, namely those in whom the operation was performed using a new HS handpiece (NHS; 108 patients) and those assigned to conventional hemostasis (CH; 103 patients). The two surgical groups were compared regarding patients' age and sex, tumor size, location, histotype and local invasiveness assessed by American Joint Cancer Committee stage, operative time, fluid content in the suction balloon (drainage volume) during the first 1-3 days after surgery, hospital stay and complications. RESULTS: Ultrasonic energy delivered through an HS has been shown to be safe and to produce minimal damage to the surrounding tissues because of its minimal heat production. Electrical devices allow hemostatic control in vessels up to 3 mm in diameter, while HS can coagulate vessels up to 5 mm in diameter; thus, HS allows not only better control of bleeding but also of lymphorrhea. In fact, the amount of fluid collected in the drainage was significantly lower in the NHS group compared to the CH group. Protein depletion influences the patient's regenerative capacity and thus also the occurrence of complications and recovery time. CONCLUSION: NHS is a useful device in colon surgery; it facilitates surgical maneuvers and reduces operative times and blood and lymphatic losses, allowing satisfactory maintenance of protein storage. This results in a lower incidence of complications and faster recovery by patients.

Concomitant gastrointestinal stromal tumor of the stomach and gastric adenocarcinoma in a patient with billroth 2 resection.

Background. With this study we focus on the etiopathogenesis and on the therapy of the simultaneous occurrence of Gastric gastrointestinal stromal tumor (gGIST) and adenocarcinoma of the stomach in a patient with Billroth II gastric resection (BIIGR). We report the first case of this event and a review of the literature. Methods. A 70-year-old man with a BIIGR, affected by adenocarcinoma of the stomach, was successfully treated with total gastrectomy. The histological examination showed a gastric adenocarcinoma with a synchronous GIST sized 2 cm and S-100, CD117, and CD34 positive. The mutation of PDGFR gene was detected. Discussion. This tumor is a rare mesenchymal neoplasm of the gastrointestinal tract. Few cases of synchronous gastric adenocarcinoma and GIST are observed in the literature and no case in patients with BIIGR. Various hypotheses have been proposed to explain this occurrence. It is frequently attributed to Metallothioneins genes mutations or embryological abnormalities, but this has not been proven yet. We suggest a hypothesis about the etiopathogenesis of this event in a BIIGR patient. Conclusion. GIST may occur synchronously with gastric adenocarcinoma. This simultaneous occurrence needs more studies to be proven. The study of Cajal cells' proliferation signalling is crucial to demonstrate our hypotesis.