ABSTRACT
INTRODUCTION: Sleeve gastrectomy (SG) is currently the most frequently performed procedure for obesity worldwide. Staple line reinforcement (SLR) has been suggested as a strategy to reduce the risk of staple line leak or bleeding; however, its use for SG in the United Kingdom (UK) is unknown. This study examined the effect of SLR on the development of postoperative complications from SG using a large national dataset from the UK. METHODS: Patients undergoing either primary or revision SG over 10 years from Jan 2012 to Dec 2021 were identified by the National Bariatric Surgery Registry. Comparative and logistic regression analyses were undertaken to determine the effect of SLR on staple line leak and bleeding. RESULTS: During this time, 14,231 patients underwent SG for whom there were complete data. Of these, 76.5% were female and the median age was 46 years (IQR: 36-53). The rate of surgical complications was 2.3% (n = 219/14,231). The incidence of bleeding was 1.3% (n = 179/14,231) and leak was 1.0% (n = 140/14,231). Over time, the use of SLR of any variety declined significantly from 99.7% in 2012 to 57.3% in 2021 (p < 0.001). Multivariable (adjusted) regression analysis demonstrated that neither the use of nor the type of reinforcement had any effect on the rate of bleeding or leaking. CONCLUSION: SLR for SG has declined in the UK since 2012. There were no differences in staple line leak or bleed with or without reinforcement.
Subject(s)
Anastomotic Leak , Bariatric Surgery , Gastrectomy , Postoperative Hemorrhage , Registries , Surgical Stapling , Humans , Female , Middle Aged , Male , United Kingdom/epidemiology , Adult , Gastrectomy/adverse effects , Gastrectomy/methods , Surgical Stapling/adverse effects , Surgical Stapling/methods , Bariatric Surgery/adverse effects , Bariatric Surgery/methods , Anastomotic Leak/epidemiology , Anastomotic Leak/prevention & control , Anastomotic Leak/etiology , Postoperative Hemorrhage/epidemiology , Postoperative Hemorrhage/etiology , Postoperative Hemorrhage/prevention & control , Obesity, Morbid/surgery , Incidence , Retrospective StudiesABSTRACT
Laparoscopic Roux-en-Y gastric bypass (RYGB) is crucial for significant weight reduction and treating obesity-related issues. However, the impact of gastrojejunostomy (GJ) anastomosis diameter on weight loss remains unclear. We investigate this influence on post-RYGB weight loss outcomes. A systematic search was conducted. Six studies met the inclusion criteria, showing varied GJ diameters and follow-up durations (1-5 years). Smaller GJ diameters generally correlated with greater short-to-medium-term weight loss, with a threshold beyond which complications like stenosis increased. Studies had moderate-to-low bias risk, emphasizing the need for precise GJ area quantification post-operation. This review highlights a negative association between smaller GJ diameters and post-RYGB weight loss, advocating for standardized measurement techniques. Future research should explore intra-operative and AI-driven methods for optimizing GJ diameter determination.
Subject(s)
Gastric Bypass , Laparoscopy , Obesity, Morbid , Weight Loss , Humans , Gastric Bypass/adverse effects , Gastric Bypass/methods , Obesity, Morbid/surgery , Laparoscopy/methods , Female , Treatment Outcome , Male , Adult , Middle AgedABSTRACT
BACKGROUND: Emergency general surgery (EGS) is a major part of the provision of healthcare, and patients undergoing EGS are at elevated risk of morbidity and mortality. This study aimed to determine factors contributing to patients losing their independence and being discharged to residential and nursing homes having previously lived in their own residences. METHODS: Our local data uploaded to the National Emergency Laparotomy Audit (NELA) (2014-2022) were analyzed. This national database encompasses all major EGS cases undertaken in the United Kingdom. The variables considered were patient demographics, American Society of Anesthesiologists score, admission and discharge dates, presenting pathology, operation type, and discharge destination. Comparative analyses segmented patients based on postdischarge EGS destinations. Multivariable logistic regression identified factors linked to residential/nursing home placement after discharge. Significance was set at P < .05. RESULTS: Data from all patients in the NELA database (n = 1611) were analyzed. Approximately 1 in 10 patients older than 70 years never returned home. Patients requiring additional support were on average 8.6 years older (P = .008). At older than 80 years, the need for extra social support increased substantially with each increasing year in age, and those older than 85 years were more than twice as likely to require extra support than 80-year-olds (P < .001). Patients who died were 11.4 years older than those discharged without additional support (P < .001). CONCLUSION: A significant proportion of patients, particularly the elderly, do not return to their usual place of residence and require a higher level of care postemergency surgery. These important social factors need to be considered before operating given that they may have significant quality of life and economic implications.
Subject(s)
Nursing Homes , Patient Discharge , Surgical Procedures, Operative , Humans , Aged , Male , Female , Aged, 80 and over , Patient Discharge/statistics & numerical data , Surgical Procedures, Operative/statistics & numerical data , Middle Aged , Nursing Homes/statistics & numerical data , United Kingdom , Emergencies , Social Support , Databases, Factual , Age Factors , Adult , Independent Living/statistics & numerical data , General Surgery/statistics & numerical data , Acute Care SurgeryABSTRACT
The aim of this meta-analysis was to compare the effects of LRYGB and LSG on dyslipidemia. Studies comparing the effects of LRYGB and LSG on dyslipidemia with follow-up of 12 months or more were included. Twenty-four studies comprising seven RCTs and 17 comparative observational studies were included. Meta-analysis of RCTs (n=487) showed that improvement/resolution of dyslipidemia was better after LRYGB (68.5%, n=161/235) compared to LSG (48.4%, n=122/252). Patients undergoing LRYGB were more than twice as likely to experience improvement/resolution in dyslipidemia compared to those undergoing LSG (OR 2.28, 95% CI 1.21-4.29, p=0.010). Both LRGYB and LSG appears effective in improving dyslipidemia at >12 months after surgery; however, this improvement is more than twice higher after LRYGB compared to LSG.
Subject(s)
Dyslipidemias , Gastric Bypass , Laparoscopy , Obesity, Morbid , Humans , Obesity, Morbid/surgery , Treatment Outcome , Gastrectomy/methods , Female , Male , Weight Loss , Randomized Controlled Trials as Topic , Adult , Observational Studies as Topic , Middle AgedABSTRACT
BACKGROUND: Enhanced Recovery After Surgery (ERAS) programs have been widely adopted in bariatric surgery. However, not all patients are successfully managed in the ERAS setting and there is currently little way of predicting the patients who will deviate from the program. Early identification of these patients could allow for more tailored protocols to be implemented preoperatively to address the issues, thereby improving patient outcomes. OBJECTIVES: The aim of this study was to elucidate the factors which preclude discharge by comparing patients who were successfully discharged by the end of the first postoperative day (POD 0/1) to those who stayed longer, including revisional surgery in this analysis. SETTING: A tertiary, high-volume Bariatric Centre, United Kingdom. METHODS: A retrospective analysis was performed of all patients undergoing bariatric surgery in a single centre in 1 year. Multivariate analyses compared patient and operative variables between patients who were discharged on POD 0/1 and those who stayed longer. RESULTS: A total of 288 bariatric operations were performed: 78% of operations performed were laparoscopic Roux-en-Y gastric bypass; 22% laparoscopic sleeve gastrectomy. Of these cases, 13% were revisional operations. Four patients returned to theatre on the index admission. 81% of patients were discharged by POD 0/1. A re-presentation within 30 days was seen in 6% of patients. There was no significant difference in length of stay for the type of operation performed (P = .86). Patients who had a revisional procedure were not more likely to stay longer. Length of stay was also independent of age, BMI, and comorbidities. Caucasian patients were more likely to be discharged on POD 0/1 than those of other ethnicities (90% versus 78%; P = .02). Operations performed by trainee surgeons, under consultant supervision, were significantly more likely to be discharged on POD 0/1 (P = .03). However, a logistic regression analysis was unable to predict patients who had a prolonged stay. CONCLUSIONS: Patient length of stay is independent of BMI, operation, and comorbidities and these factors do not need special consideration in ERAS pathways. Patients undergoing revisional procedures can be managed in the same way as those having primary procedures, with a routine POD 0/1 discharge. However, the impact of individual patient factors, and their interaction, is complex and cannot predict overstay.
Subject(s)
Bariatric Surgery , Enhanced Recovery After Surgery , Length of Stay , Obesity, Morbid , Patient Discharge , Humans , Retrospective Studies , Female , Male , Bariatric Surgery/statistics & numerical data , Bariatric Surgery/methods , Patient Discharge/statistics & numerical data , Adult , Obesity, Morbid/surgery , Length of Stay/statistics & numerical data , Middle Aged , Reoperation/statistics & numerical dataABSTRACT
Obesity has reached pandemic levels globally. Surgical management of obesity aims to establish metabolic control, weight loss and resolution of multiple health conditions and to improve quality of life. Here, we examine the role of surgery in the management of obesity within the context of a multidisciplinary team involving a variety of healthcare professionals. We highlight the importance of patient selection, perioperative care, the various types of bariatric surgery currently available as well as emerging procedures. In addition to clarifying the different types of procedure, we also examine the potential complications and issues of weight regain and failure to lose weight. Ultimately, bariatric surgery remains comparatively safe and with generally excellent results in terms of control of existing obesity-related conditions; with the ever-increasing number of patients living with obesity, the scope of bariatric surgery is thus likely to increase.
Subject(s)
Bariatric Surgery , Obesity, Morbid , Humans , Quality of Life , Cross-Sectional Studies , Multimorbidity , Obesity/complications , Obesity/surgery , Bariatric Surgery/methodsABSTRACT
The laparoscopic approach for dealing with bariatric complications has become the gold standard of modern practice. The aim of this study is to assess the role of relaparoscopy as a diagnostic and therapeutic approach towards managing complications and improving 30-day outcome. MATERIALS AND METHODS: A retrospective review of a prospectively maintained database was conducted in a tertiary bariatric unit. Data were collected on all bariatric surgical procedures performed between March 2013 and March 2019. Any patient who was returned to theatre for a suspected serious complication was identified and their outcome studied. RESULTS: Over the 5-year study period, the total number of operations performed was 1660 (981 laparoscopic gastric bypass (LRYGB), 612 laparoscopic sleeve gastrectomy (LSG) and 67 revisional bariatric operations). Early postoperative complications (in hospital or within 30 days of surgery) that lead to reoperation were recorded in 33 patients (1.9%). These complications occurred after LRYGB in 26 patients (2.65%) and LSG in 7 patients (1.14%), respectively. Anastomotic leaks occurred in 1.1% of LRYGB, whilst 0.6% of patients have jejuno-jejunostomy obstruction. Obstruction at the gastro-jejunostomy anastomosis occurred in one patient. Following LSG, one mortality was recorded following bleeding from the staple line (0.06%) and five patients (0.3%) had leaks from the staple line. Thirty-one reoperations were performed laparoscopically, and two were converted to the open approach, whilst 2 operations were planned as open from the outset. CONCLUSION: Relaparoscopy is an effective and safe approach to the management of clinically or radiologically suspected early complications after bariatric surgery. Graphical abstract.
Subject(s)
Bariatric Surgery , Gastric Bypass , Gastroplasty , Laparoscopy , Obesity, Morbid , Bariatric Surgery/adverse effects , Gastrectomy/adverse effects , Gastric Bypass/adverse effects , Humans , Obesity, Morbid/surgery , Postoperative Complications/epidemiology , Postoperative Complications/surgery , Reoperation , Retrospective Studies , Treatment OutcomeABSTRACT
SARS-CoV-2 is a virus that is the cause of a serious life-threatening disease known as COVID-19. It was first noted to have occurred in Wuhan, China in November 2019 and the WHO reported the first case on December 31, 2019. The outbreak was declared a global pandemic on March 11, 2020 and by May 30, 2020, a total of 5 899 866 positive cases were registered including 364 891 deaths. SARS-CoV-2 primarily targets the lung and enters the body through ACE2 receptors. Typical symptoms of COVID-19 include fever, cough, shortness of breath and fatigue, yet some atypical symptoms like loss of smell and taste have also been described. 20% require hospital admission due to severe disease, a third of whom need intensive support. Treatment is primarily supportive, however, prognosis is dismal in those who need invasive ventilation. Trials are ongoing to discover effective vaccines and drugs to combat the disease. Preventive strategies aim at reducing the transmission of disease by contact tracing, washing of hands, use of face masks and government-led lockdown of unnecessary activities to reduce the risk of transmission.
Subject(s)
COVID-19 , SARS-CoV-2 , COVID-19/diagnosis , COVID-19/epidemiology , COVID-19/therapy , HumansABSTRACT
INTRODUCTION: Literature on long-term (> 10 years) outcomes in terms of weight loss, resolution of co-morbidities, and quality of life (QoL) after bariatric surgery is limited. The aim of this study was to investigate the excess weight loss (EWL), resolution of comorbidities, and QoL more than 10 years after laparoscopic Roux-en-Y gastric bypass (LRYGB) using the Bariatric Analysis and Reporting Outcome System (BAROS). METHODS: Data on patient demographics, weight, body mass index (BMI), comorbidities, type of surgery, complications, and QoL were collected from a prospectively maintained database. RESULTS: A total of 92 patients out of 104 who underwent LRYGB during the study period and completed a median follow-up of 130 months were successfully contacted. The median age was 48 years (IQR 42-54 years) and 85.9% had a BMI of more than 40. The median excess weight loss (EWL) was 46.5% (IQR 27.9-64.3%). Type 2 diabetes mellitus reduced from 56.5 to 23.9% (p < 0.001), hypertension from 51.1 to 39.1% (p = 0.016), and obstructive sleep apnoea from 33.7 to 12.0% (p < 0.001). Participants reported feeling better (median 0.2, IQR 0.2-0.4), engaging in more physical activity (0.1, IQR 0.1-0.3), having more satisfactory social contacts (0.4, IQR 0.2-0.5), a better ability to work (0.3, IQR - 0.1-0.5), and a healthier approach to food (0.2, IQR - 0.3-0.3) at the end of follow-up. CONCLUSION: LRYGB leads to positive outcomes in terms of weight loss, reduction in comorbidities, and improvement in QoL at a follow-up of more than 10 years.
Subject(s)
Diabetes Mellitus, Type 2 , Gastric Bypass , Laparoscopy , Obesity, Morbid , Body Mass Index , Diabetes Mellitus, Type 2/epidemiology , Humans , Middle Aged , Obesity, Morbid/surgery , Quality of Life , Retrospective Studies , Treatment OutcomeABSTRACT
BACKGROUND: Obesity leads to impairment of physical activity as measured by an inability to perform activities of daily living. Literature on the effect of bariatric surgery on physical activity is conflicting. OBJECTIVE: The aim of this study was to perform a meta-analysis of the effect of bariatric surgery on physical activity from studies employing objective measurement and self-reporting of physical activity before and after bariatric surgery. METHODS: Bibliographic databases were searched systematically for relevant literature until December 31, 2018. Studies employing objective and self-reported measurement of physical activity were included. Study quality was assessed using Risk of Bias in Nonrandomized Studies - of Interventions tool. Meta-analysis was performed using random effects model and presented as standardized mean difference (SMD) with 95% confidence intervals (CI). RESULTS: Twenty studies identified 5886 patients suitable for the analysis. Physical activity showed significant improvement at 0-6 months (SMD: .50; 95% CI: .25-.76; P = .0001), >6-12 months (SMD: .58; 95% CI: .26-.91; P = .0004), and >12-36 months (SMD: .82; 95% CI: .27-1.36; P = .004) after bariatric surgery. Self-reported assessment after bariatric surgery showed significant improvement at 0-6 months (SMD: .65; 95% CI: .29-1.01; P = .0004), >6 to 12 months (SMD: .53; 95% CI: .18-.88; P = .003), and >12-36 months (SMD: .51; 95% CI: .46-.55; P < .00001). Objective assessment after bariatric surgery did not show improvement at 0-6 months (SMD: .31; 95%CI:-.05-.66; P = .09), but showed significant improvement at >6-12 months (SMD: .85; 95% CI:-.07-1.62; P = .03), and >12-36 months (SMD: 1.99; 95% CI: 1.13-2.86; P < .00001) after bariatric surgery. CONCLUSIONS: Bariatric surgery improves physical activity significantly in a population with obesity up to 3 years after surgery. Objective measurement of physical activity does not show significant improvement within 6 months of bariatric surgery but begins to improve at >6 months. Self-reported measurement of physical activity begins to show improvement within 6 months of a bariatric procedure.
Subject(s)
Bariatric Surgery , Exercise , Obesity/psychology , Obesity/surgery , HumansABSTRACT
BACKGROUND: Obesity is associated with a twofold risk of gastroesophageal reflux disease (GERD) and thrice the risk of Barrett's esophagus (BE). Roux-en-Y gastric bypass (RYGB) leads to weight loss and improvement of GERD in population with obesity, but its effect on BE is less clear. METHODS: Bibliographic databases were searched systematically for relevant articles till January 31, 2019. Studies evaluating the effect of RYGB on BE with preoperative and postoperative endoscopy and biopsy were included. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) tool. Meta-analysis was conducted using Mantel-Haenszel, random effects model and presented as risk difference (RD) or odds ratio (OR) with 95% confidence intervals. RESULTS: Eight studies with 10,779 patients undergoing RYGB reported on 117 patients with BE with follow-up of > 1 year. Significant regression of BE after RYGB was observed (RD - 0.56.95% c.i. - 0.69 to - 0.43; P < 0.001). Subgroup analysis showed regression of both short-segment BE [ssBE] (RD - 0.51.95% c.i. - 0.68 to - 0.33; P < 0.001) and long-segment BE [lsBE] (RD - 0.46.95% c.i. - 0.71 to - 0.21; P < 0.001). RYGB also caused improvement in GERD in patients of BE (RD - 0.93, 95% c.i. - 1.04 to - 0.81; P < 0.001). RYGB was strongly associated with regression of BE compared with progression (OR 31.2.95% c.i. 11.37 to 85.63; P < 0.001). CONCLUSIONS: RYGB leads to significant improvement of BE at > 1 year after surgery in terms of regression and resolution of the associated GERD. Both ssBE and lsBE improve after RYGB significantly.
Subject(s)
Barrett Esophagus , Gastric Bypass/statistics & numerical data , Obesity , Barrett Esophagus/complications , Barrett Esophagus/epidemiology , Barrett Esophagus/pathology , Humans , Obesity/complications , Obesity/surgeryABSTRACT
BACKGROUND: Secondary bariatric procedures represent a challenge to both patients and surgeons. The objective of this study was to explore the patterns of recurrence and modalities of secondary bariatric procedures in a tertiary bariatric centre. MATERIALS AND METHODS: A retrospective analysis of patients who underwent secondary bariatric procedures after laparoscopic adjustable gastric band (AGB), sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) from April 2007 to March 2017. RESULTS: Overall, 3266 bariatric procedures were performed, and secondary bariatric procedures were required for 45 (1.4%) patients (28 AGB, 14 SG, 3 RYGB). Twenty-six (57.8%) patients underwent conversion to RYGB, eight (17.8%) patients underwent conversion to SG, seven (15.6%) patients were converted to duodenal switch (DS), two (4.4%) patients had revision of gastrojejunal anastomosis, one (2.2%) patient underwent revision of gastric pouch and one (2.2%) patient had replacement of AGB. Mean change in BMI and %TWL at 18 months were 8.5 ± 3.9 kg/m2 and 17.6 ± 8.2 respectively after revision of AGB. Mean change in BMI and %TWL at 18 months were 11.7 ± 11.2 kg/m2 and 18.4 ± 13.2 respectively after revision of SG. Mean change in BMI and %TWL at 18 months were 2.6 ± 3.0 kg/m2 and 6.9 ± 6.8 respectively after revision of RYGB. No mortality was reported after revision procedures. CONCLUSION: Weight regain, inadequate weight loss and reflux were the main reasons for performing secondary bariatric procedures. The main revision procedures performed were RYGB and SG especially for failed AGB.
Subject(s)
Bariatric Surgery , Reoperation , Bariatric Surgery/adverse effects , Bariatric Surgery/methods , Bariatric Surgery/statistics & numerical data , Humans , Obesity, Morbid/surgery , Prevalence , Reoperation/adverse effects , Reoperation/methods , Reoperation/statistics & numerical data , Retrospective Studies , Treatment Outcome , Weight LossABSTRACT
BACKGROUND: Ventral hernias (VH) are frequently encountered in patients with morbid obesity. Concomitant ventral hernia repair (VHR) and bariatric surgery (BS) is practiced but still controversial. Wound-related complications (seroma, hematoma, wound infection) and hernia recurrence rates are possible inhibitor factors. We aimed to estimate the rate of complications from concomitant BS (laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy) and VHR and identify patient subgroups at higher risk of complications from synchronous repair. METHODS: A retrospective analysis of successive 106 patients who underwent concomitant BS + VHR at our institute (09/2007 to 09/2015) was performed using data from patients' record. Parameters considered were: type of repair (open/laparoscopic and primary closure/mesh), size and type of hernia (< 5 cm, 5-10 cm, > 10 cm and primary/incisional), patient gender and comorbidities. RESULTS: One hundred and six patients underwent concomitant BS and VHR. Fifty-nine had laparoscopic VHR and 47 open. Hernias recurred in 5 (8.47%) laparoscopic and 7 (14.89%) open VHR. Wound-related complications were common in open (15%) vs. laparoscopic (11.7%) VHR. Patients with VH recurrence included 8 (75%) with defects > 5 cm, 10 (83%) female, and all had BMI > 45. Six patients had wound infection, 5 of which had type 2 diabetes mellitus. Six patients had hematoma, 5 of which underwent mesh repairs. Finally, four patients developed seroma (BMI > 48, defects > 5 cm, laparoscopic mesh repair). CONCLUSION: Synchronous VHR and BS in a bariatric unit is feasible with low recurrence rate. Laparoscopic VHR has lower complication rates than open, apart from seroma formation. Patients with diabetes have higher risk of infection.
Subject(s)
Gastrectomy/adverse effects , Gastric Bypass/adverse effects , Hernia, Ventral/surgery , Herniorrhaphy/adverse effects , Obesity, Morbid/surgery , Postoperative Complications/epidemiology , Adult , Aged , Diabetes Mellitus, Type 2/complications , Female , Hernia, Ventral/complications , Herniorrhaphy/methods , Humans , Laparoscopy/adverse effects , Male , Middle Aged , Obesity, Morbid/complications , Postoperative Complications/etiology , Recurrence , Retrospective Studies , Treatment Outcome , United KingdomABSTRACT
BACKGROUND: Feeding jejunostomy has increasingly become a standard adjunctive procedure during major esophago-gastric resections. They provide nutritional support during the post-operative period as required. However, significant early complications have been reported, most notably small bowel necrosis. Literature reports have been restricted to case reports or series. This study aims to determine the frequency of this complication in a cohort of patients undergoing esophago-gastric resection, and identify any difference in the risk of this complication between patients undergoing esophagectomy and gastrectomy. METHODS: Consecutive patients who had esophago-gastric resections for malignancy and who had a feeding jejunostomy placed were identified from a prospectively maintained database at Leicester Royal Infirmary during the years 2009-2015. Case notes were reviewed to extract information relating to demographics, presenting features and clinical outcome. RESULTS: The study included 360 patients, 285 of which had esophagectomy and 75 had gastrectomy. There were no small bowel complications among esophagectomy patients (0%), while six patients who had total gastrectomy developed small bowel ischemia or necrosis (8%), p = 0.05, in spite of an identical feeding regimen. Every patient that developed the complication underwent surgery with five out six having resection of the infarcted segment and double-barrel stoma formation. A 6-8-week period of parenteral nutrition was required before stoma reversal. One patient had leucocytosis on the day of diagnosis. The other five patients showed no derangements in biochemical or clinical parameters in the preceding 48 h. Five of the six patients survived. CONCLUSIONS: Small bowel necrosis and perforation is a life-threatening complication of feeding jejunostomy. In our cohort, it happened exclusively in total gastrectomy patients. Antecedent signs were lacking. The condition requires prompt attention with earlier use of CT scanning and a return to the operating room. The presence of pneumatosis intestinalis on CT scan should prompt surgical intervention that improves survival.
Subject(s)
Esophagectomy/adverse effects , Gastrectomy/adverse effects , Intestine, Small/blood supply , Intestine, Small/pathology , Ischemia/etiology , Jejunostomy/adverse effects , Postoperative Complications/etiology , Aged , Cohort Studies , Elective Surgical Procedures/adverse effects , Enteral Nutrition , Female , Gastrointestinal Diseases/etiology , Humans , Ischemia/surgery , Male , Middle Aged , Necrosis/etiology , Necrosis/surgery , Parenteral Nutrition, Total , Postoperative Complications/surgeryABSTRACT
BACKGROUND: Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are functionally the most important omega-3 polyunsaturated fatty acids (PUFAs). Oral supply of these fatty acids increases their levels in plasma and cell membranes, often at the expense of the omega-6 PUFAs arachidonic acid (ARA) and linoleic acid. This results in an altered pattern of lipid mediator production to one which is less pro-inflammatory. We investigated whether short term intravenous supply of omega-3 PUFAs could change the levels of EPA, DHA, ARA and linoleic acid in plasma and erythrocytes in patients with hepatic colorectal metastases. METHODS: Twenty patients were randomised to receive a 72 hour infusion of total parenteral nutrition with (treatment group) or without (control group) omega-3 PUFAs. EPA, DHA, ARA and linoleic acid were measured in plasma phosphatidylcholine (PC) and erythrocytes at several times points up to the end of infusion and 5 to 12 days (mean 9 days) after stopping the infusion. RESULTS: The treatment group showed increases in plasma PC EPA and DHA and erythrocyte EPA and decreases in plasma PC and erythrocyte linoleic acid, with effects most evident late in the infusion period. Plasma PC and erythrocyte EPA and linoleic acid all returned to baseline levels after the 5-12 day washout. Plasma PC DHA remained elevated above baseline after washout. CONCLUSIONS: Intravenous supply of omega-3 PUFAs results in a rapid increase of EPA and DHA in plasma PC and of EPA in erythrocytes. These findings suggest that infusion of omega-3 PUFAs could be used to induce a rapid effect especially in targeting inflammation.
Subject(s)
Colorectal Neoplasms/blood , Fatty Acids, Omega-3/administration & dosage , Fatty Acids, Omega-6/administration & dosage , Inflammation/blood , Adolescent , Adult , Aged , Aged, 80 and over , Arachidonic Acid/blood , Child , Colorectal Neoplasms/pathology , Docosahexaenoic Acids/blood , Eicosapentaenoic Acid/blood , Female , Humans , Inflammation/drug therapy , Linoleic Acid/blood , Liver Neoplasms/drug therapy , Liver Neoplasms/metabolism , Liver Neoplasms/secondary , Male , Middle AgedABSTRACT
INTRODUCTION: Mediators derived from the n-6 polyunsaturated fatty acid (PUFA) arachidonic acid oxidation have been shown to have tumour promoting effects in experimental models, while n-3 PUFAs are thought to be protective. Here we report fatty acid concentrations in hepatic colorectal metastases compared to liver tissue without tumour in humans. METHODS: Twenty patients with colorectal liver metastasis were randomized to receive a 72 h infusion of parenteral nutrition with or without n-3 PUFAs. Histological samples from liver metastases and liver tissue without tumour were obtained from 15 patients at the time of their subsequent liver resection (mean 8 days (range 4-12) post-infusion) and the fatty acid composition determined by gas chromatography. RESULTS: There were no significant differences in fatty acid composition between the two intervention groups. When data from all patients were combined, liver tissue without tumour had a higher content of both n-3 and n-6 PUFAs and a lower content of oleic acid and total n-9 fatty acids compared with tumour tissue (p<0.0001, 0.0002,<0.0001 and <0.0001, respectively). The n-6/n-3 PUFA ratio was found to be higher in tumour tissue than tissue without tumour (p<0.0001). CONCLUSIONS: Hepatic colorectal adenocarcinoma metastases have a higher content of n-9 fatty acids and a lower content of n-6 and n-3 PUFAs than liver tissue without tumour.
Subject(s)
Adenocarcinoma/chemistry , Colorectal Neoplasms/chemistry , Docosahexaenoic Acids/administration & dosage , Eicosapentaenoic Acid/administration & dosage , Liver Neoplasms/chemistry , Liver/chemistry , Adenocarcinoma/metabolism , Adenocarcinoma/secondary , Adult , Aged , Case-Control Studies , Colorectal Neoplasms/metabolism , Colorectal Neoplasms/pathology , Docosahexaenoic Acids/analysis , Eicosapentaenoic Acid/analysis , Fatty Acids, Omega-3/analysis , Fatty Acids, Omega-6/analysis , Female , Humans , Liver/metabolism , Liver/pathology , Liver Neoplasms/metabolism , Liver Neoplasms/secondary , Male , Middle AgedABSTRACT
Although gemcitabine remains current first-line chemotherapy for patients with advanced pancreatic cancer, median survival times have not improved significantly since its introduction 15 years ago. Of the phase III trials which have investigated alternative regimens to single-agent gemcitabine, most have used combination regimens as the investigational arm. Accurate data on median overall, progression-free survival and objective response rates is important, for two principle reasons: advising patients about their prognosis and when powering phase II trials and evaluating the results of single-armed trials. This study aims to pool results from published randomized trials to date. Twenty-one randomized phase III trials involving a total of 6348 patients were identified from 1997 to 2010. Only one trial investigating a novel agent in combination with gemcitabine showed a significantly prolonged median and progression-free survival compared with single-agent gemcitabine. Pooled median and progression-free survivals for the single-agent gemcitabine arm involving 3171 patients across all studies were 6.15 and 3.3 months, respectively. Length of survival for patients with advanced pancreatic cancer remains disappointing. Further trials of novel agents to complement or replace gemcitabine are indicated.
Subject(s)
Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Deoxycytidine/analogs & derivatives , Pancreatic Neoplasms/drug therapy , Pancreatic Neoplasms/mortality , Antineoplastic Combined Chemotherapy Protocols/adverse effects , Clinical Trials, Phase III as Topic , Deoxycytidine/adverse effects , Deoxycytidine/therapeutic use , Dose-Response Relationship, Drug , Drug Administration Schedule , Female , Humans , Male , Maximum Tolerated Dose , Neoplasm Staging , Pancreatic Neoplasms/pathology , Pancreatic Neoplasms/surgery , Prognosis , Randomized Controlled Trials as Topic , Survival Analysis , GemcitabineABSTRACT
INTRODUCTION: The aim of this review is to summarize the available evidence for changes in bile composition following liver surgery and assess their use in predicting post-operative complications. MATERIALS AND METHODS: A literature search was undertaken for all studies focusing on bile composition, bile volume and analysis. Articles were selected from MEDLINE, Embase and the Cochrane Central Register of Controlled Trials databases up to May 2009. RESULTS: Low values of pre-operative bilirubin diglucuronide predict reduced post-operative liver function and the occurrence of jaundice. Low concentrations of hepatocyte growth factor and interleukin-6 in bile following surgery are associated with the subsequent development of liver failure and are probably surrogate markers for situations where the resultant hepatic regeneration is inadequate. CONCLUSIONS: Analysis of the composition and quality of bile is probably underused as a tool for the pre-operative screening and early post-operative monitoring of patients at high risk of developing liver failure following major hepatobiliary procedures.
Subject(s)
Bile/chemistry , Liver/surgery , Bilirubin/analogs & derivatives , Bilirubin/analysis , Hepatocyte Growth Factor/analysis , Humans , Interleukin-6/analysis , Jaundice/etiology , Liver/physiology , Liver Failure/diagnosis , Liver Regeneration/physiology , Monitoring, Physiologic , Postoperative PeriodABSTRACT
Gallbladder agenesis is uncommon. In contrast, liver haemangiomas are the most common type of benign liver lesions. We describe the first documented case of gallbladder agenesis where the clinical presentation was consistent with biliary colic, and radiological investigation suggested the presence of gallstones. Subsequent operative findings revealed a solitary haemangioma of the liver sited in the normal position of the gallbladder fossa but with absence of the gallbladder. It is important that clinicians should keep gallbladder agenesis in mind when the gallbladder appears abnormal on preoperative imaging studies and cannot be found at laparoscopy. As symptoms will improve in 98% of cases, it is very important to avoid unnecessary intervention in patients who have a negative laparoscopy. The clinical presentation, investigations, and operative findings are discussed with a review of other relevant reported cases in the literature.