Critical assessment of the current guidelines for the management and treatment of morbidly obese patients.

An interdisciplinary panel of specialists met in Mallorca in the first European Symposium on Morbid Obesity entitled; "Morbid Obesity, an Interdisciplinary Approach". During the two and half days of the meeting, the participants discussed several aspects related to pathogenesis, evaluation, and treatment of morbid obesity. The expert panel included basic research scientists, dietitians and nutritionists, exercise physiologists, endocrinologists, psychiatrists, cardiologists, pneumonologists, anesthesiologists, and bariatric surgeons with expertise in the different weight loss surgeries. The symposium was sponsored by the Balearic Islands Health Department; however, this statement is an independent report of the panel and is not a policy statement of any of the sponsors or endorsers of the Symposium. The prevalence of morbid obesity, the most severe state of the disease, has become epidemic. The current recommendations for the therapy of the morbidly obese comes as a result of a National Institutes of Health (NIH) Consensus Conference held in 1991 and subsequently reviewed in 2004 by the American Society for Bariatric Surgery. This document reviews the work-up evaluation of the morbidly obese patient, the current status of the indications for bariatric surgery and which type of procedure should be recommended; it also brings up for discussion some important real-life clinical practice issues, which should be taken into consideration when evaluating and treating morbidly obese patients. Finally, it also goes through current scientific evidence supporting the potential effectiveness of medical therapy as treatment of patients with morbid obesity.

Laparoscopic biliopancreatic diversion with duodenal switch: technique and initial experience.

BACKGROUND: The duodenal Switch (DS) is a variant of the biliopancreatic diversion (BPD) for the surgical treatment of morbid obesity. MATERIALS AND METHODS: The laparoscopic DS (LapDS) operation is described, and the early surgical outcomes of 16 patients are reported. RESULTS: Postoperative stay was 5 to 8 days. Local wound infection at a trocar site was the most common local complication. CONCLUSION: LapDS is an advanced, complex and feasible technique in bariatric surgery.

Drenaje no quirúrgico del pseudoquiste de páncreas / Non surgical draimage of pancreatic pseudocyst

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Cruce duodenal por laparoscopia en el tratamiento de la obesidad mórbida: técnica y estudio preliminar / Laparoscopic duodenal switch in morbid obesity. Technique and preliminar study

Introducción. El cruce duodenal es una variante de la derivación biliopancreática en el tratamiento de la obesidad mórbida. Pacientes y método. Se describe la técnica de cruce duodenal realizada por laparoscopia y curso preliminar en dos pacientes operadas. Resultados. La estancia hospitalaria fue de 5 y 7 días. Conclusión. El cruce duodenal por laparoscopia es una técnica compleja, avanzada y posible en la cirugía bariátrica (AU)

Duodenal switch: an effective therapy for morbid obesity--intermediate results.

BACKGROUND: The duodenal switch (DS) is a variant of the biliopancreatic diversion (BPD), with a vertical subtotal gastrectomy and pylorus preservation. METHODS: DS was used to treat morbid obesity in 125 patients, with mean BMI 50, with 65% of the patients super obese (SO). Patients have been followed for an intermediate period. RESULTS: The percentage of excess weight loss (%EWL) was > 70% at 1 year, and reached 81.4% at 5 years when 97% of the patients had a %EWL > 50%. Comorbidities were cured or improved in all patients. CONCLUSION: DS was very effective for the treatment of the morbid obesity in the SO patients.

El cruce duodenal: una terapia efectiva en la obesidad mórbida. Estudio intermedio / Duodenal switch: an effective therapy for morbid obesity. An intermediate study

El cruce duodenal es una variante de la derivación biliopancreática. Se describen la técnica, su morbimortalidad, los resultados intermedios, los efectos secundarios y las indicaciones como una técnica mixta para el tratamiento de la obesidad mórbida. El porcentaje de sobrepeso perdido se incrementa del 70 por ciento al año hasta el 81,37 por ciento a los 5 años (AU)

Sarcomas primarios de mama: casuística nacional / Primary sarcoma of the breast: national casuistics

Objetivos. Los sarcomas primarios de mama son procesos patológicos poco frecuentes (< 1 por ciento). Después de tratar 3 casos en nuestro servicio, revisamos la casuística nacional con el objetivo de conocer mejor su comportamiento clínico y el tratamiento más adecuado. Material y métodos. Revisamos 11 casos de sarcoma primario de mama, publicados desde 1988 hasta el momento actual. Todas las pacientes fueron mujeres, de edades comprendidas entre 40 y 81 años (media 56,8). Estudiamos factores pronósticos como el tipo y el grado histológico, el tamaño del tumor y el tratamiento efectuado, para relacionarlos con su evolución y supervivencia. Resultados. Los tipos histológicos hallados corresponden a 4 liposarcomas, 2 angiosarcomas, 2 histiocitomas fibrosos malignos, un leiomiosarcoma, un osteosarcoma y un sarcoma estromal. El tamaño tumoral máximo osciló entre 13 y 1,5 cm (media, 5,5). Sólo en un caso se describió un bajo grado histológico. En 9 casos a la mastectomía se asoció una linfadenectomía y en cuatro se asoció radioterapia postoperatoria. Las 2 pacientes que fallecieron lo hicieron por diseminación metastásica. Conclusiones. El factor pronóstico que más se relaciona con la incidencia de metástasis y la mortalidad es el tipo histológico (angiosarcoma y osteosarcoma); el tamaño tumoral y el grado histológico son factores coadyuvantes menos importantes y sin repercusión en las recidivas y la supervivencia. El tratamiento quirúrgico está sobrevalorado, con un 81,8 por ciento de linfadenectomías innecesarias (AU)

Immunohistochemical study of pepsinogen C expression in cutaneous malignant melanoma: association with clinicopathological parameters.

BACKGROUND: The aim of this study was to evaluate the pepsinogen C expression in malignant cutaneous melanomas and analyze its possible relationship to clinical and pathological parameters. Pepsinogen C is an aspartyl proteinase primarily involved in the digestion of proteins in the stomach and represents one of the main androgen-inducible proteins in breast cancer cells. METHOD: Tumoral pepsinogen C expression was retrospectively analyzed in 35 paraffin-embedded tissues from patients with primary malignant cutaneous melanoma and in 10 samples from 10 benign lesions (4 dermal melanocytic nevi, 4 compound melanocytic nevi and 2 dysplastic melanocytic nevi), using immunohistochemical methods. RESULTS: The benign lesions were consistently negative for pepsinogen C, whereas 20 of the 35 malignant melanomas (57%) showed positive immunostaining for pepsinogen C. The percentage of pepsinogen C-positive tumors was significantly higher in men than in women (p=0.01) and in epithelioid melanomas than in fusocellular or mixed type melanomas (p=0.003). In addition, the percentage of pepsinogen-C positive tumors was positively and significantly correlated with lesion thickness (p=0.003), Clark's level of invasion (p=0.028) and tumor stage (p<0.001). CONCLUSION: Pepsinogen C could be a new prognosticator of unfavorable outcome in cutaneous malignant melanoma.

Comentario / Commentary

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Bypass gástrico por laparoscopia: estudio preliminar / Gastric bypass using laparoscopic techniques: preliminary study

Introducción. El bypass gástrico es el "patrón oro" de las técnicas de cirugía bariátrica. El bypass gástrico por laparoscopia es una técnica avanzada y novedosa para el tratamiento de la obesidad mórbida. Paciente y métodos. Se han intervenido 16 pacientes y sólo en 6 casos se pudo completar la intervención por laparoscopia. Se describe la técnica en detalle. Resultados. El porcentaje de sobrepeso perdido supera el 70 por ciento a los 12 y 18 meses, y es superponible a la misma operación por laparotomía. Conclusión. Es una técnica compleja, con muchos detalles, y la curva de aprendizaje es muy difícil pero de un futuro innegable (AU)

Estudio Delphi de la Sociedad Valenciana de Cirugía: tratamiento quirúrgico del cáncer gástrico / A Delphi study by the Surgical Society of Valencia, Spain: surgical treatment of gastric cancer

Se presentan los resultados del primer estudio de consenso auspiciado por la Sociedad Valenciana de Cirugía sobre el tratamiento quirúrgico del cáncer gástrico. Se trata de un esudio tipo Delphi, con la participación de 31 expertos pertenecientes a la mayoría de hospitales de la Comunidad Valenciana. Los temas consensuados han versado sobre los siguientes aspectos: nutrición artificial, métodos de estadificación preoperatoria, tipo de resección y de linfadenectomía, técnicas de reconstrucción, criterios de resecabilidad y temas de organización (AU)

Comparative study of two androgen-induced markers (apolipoprotein D and pepsinogen C) in female and male breast carcinoma.

BACKGROUND: Male breast cancer (MBC) is a rare tumor in comparison to the same disease in the female population (FBC). Classical prognostic factors (tumor size, node status, estrogen receptor positivity, histological grade) have a similar prognostic value in both tumors, but MBC seems to have a worse outcome. Several markers under estrogen control have been shown with a similar incidence in breast tumors of both sexes, while androgen-induced markers have been detected in a higher percentage of breast tumors in males. AIMS AND METHODS: Our purpose was to compare in 68 MBC and in 68 FBC the expression of Pepsinogen C (Pep C) and Apolipoprotein D (Apo D), two proteins under androgen control, by immunohistochemical methods. RESULTS: Pep C was expressed by 52 of 68 (76.4%) MBC patients, whereas 34 of 68 (50%) FBC showed positive staining. Apo D was expressed by 57 of 68 (83.8%) MBC patients, while 40 of 68 (41.2%) FBC stained positively. Differences between percentages of positive expression were significant (p<0.005 for Pep C; p<0.0001 for Apo D). Moreover, differences between expression levels of Pep C and Apo D in both populations of patients were significant. The mean value of Pep C was significantly higher in male breast tumors (HSCORE = 141.3) than in the females (HSCORE = 80.3) (p<0.0001). Similarly, Apo D mean value was significantly higher in MBC (HSCORE = 161.5) than in FBC (HSCORE = 102.3) (p=0.006). CONCLUSION: These differences can open the field of a more selective hormonal therapy that should not be based on estrogen receptor status only, but also on androgen receptor status.

Expression and clinical significance of apolipoprotein D in male breast cancer and gynaecomastia.

BACKGROUND: Apolipoprotein D (Apo D) is a protein component of the human plasma lipid transport system which is present in benign and malignant human breast tissues. This study analysed the expression of Apo D in men with gynaecomastia or breast cancer, and evaluated its use as a prognostic marker in breast cancer. METHODS: Immunohistochemical expression of Apo D was examined in specimens from 15 men with gynaecomastia, two with in situ breast carcinoma and 68 with invasive male breast cancer. Median follow-up in patients with breast cancer was 44 months. RESULTS: All gynaecomastia specimens, both in situ carcinomas and 57 invasive carcinomas (84 per cent) stained positively for Apo D. Apo D values were significantly correlated with axillary node involvement and histological grade of the tumours. In men with breast cancer univariate analysis showed a statistical association between node status and Apo D content with relapse-free survival (P < 0.001) and overall survival (P < 0.05). Cox multivariate analysis showed that Apo D was a significant indicator of relapse-free survival (P = 0. 0089), but node status was the strongest factor able to predict both relapse-free (P = 0.0336) and overall (P = 0.0346) survival. CONCLUSION: Apo D was expressed in gynaecomastia and a high percentage of male breast carcinomas. There was a positive association of Apo D content in male breast tumours with favourable outcome. Apo D expression was a significant independent indicator of relapse-free survival in male breast cancer.

Expression of pepsinogen C in gynecomastias and male breast carcinomas.

Pepsinogen C is a proteolytic enzyme involved in the digestion of proteins in the stomach; it is also synthesized by a significant percentage of female breast carcinomas. In addition, it has been demonstrated that pepsinogen C is one of the few proteins induced by androgens in breast carcinoma cells. Here we evaluate the expression of pepsinogen C by immunoperoxidase staining in normal breast tissue from 3 male patients, 15 gynecomastia tissues, 2 male in situ breast carcinomas, and 68 male invasive breast carcinomas. Pepsinogen C immunostaining values were quantified in male breast tumors using the HSCORE system, which considers both the intensity and the percentage of cells staining at each intensity. The results indicated positive immunohistochemical staining for pepsinogen C in all gynecomastia tissues, the two in situ ductal carcinomas, and 52 of 68 invasive breast carcinomas (76.4%). The three normal breast tissues analyzed showed negative staining for pepsinogen C, whereas invasive tumors showed clear differences among them with regard to the intensity and percentage of staining cells. In addition, pepsinogen C scores were significantly higher in well-differentiated (grade I, 188.7) and moderately differentiated (grade II, 145.8) tumors than in poorly differentiated (grade III, 98.5) tumors (p = 0. 032). Similarly, significant differences in pepsinogen C content were found between estrogen receptor (ER)-positive tumors and ER-negative tumors (158.5 vs. 44.3, respectively; p = 0.009). Patients with pepsinogen C-positive tumors reached longer relapse-free and overall survival periods than did those with tumors with negative staining, but no statistical differences were observed between survival curves calculated for these two groups of patients. This results demonstrate expression of pepsinogen C by gynecomastias and by a high percentage of male breast carcinomas and may indicate an important role of pepsinogen C in the pathophysiology of male breast diseases.

Internal hernias and gastric perforation after a laparoscopic gastric bypass.

A 27-year-old woman underwent laparoscopic Rouxen-Y gastric bypass. A retrocolic-retrogastric herniation of most of the small bowel and later a gastric perforation due to internal hernia at the mesenteric defect of the jejuno-jejunostomy occurred. These unusual, but not rare, complications are directly related to the neoanatomy that follows gastric bypass and can lead to rapidly progressing and life-threatening situations. Proper evaluation of clinical signs and symptoms, early abdominal CT scan, and urgent operative intervention are mandatory to achieve a successful outcome.

Vertical banded gastroplasty at more than 5 years.

BACKGROUND: Optimal evaluation of the results of surgery for morbid obesity requires a long-term follow-up for at least 5 years. METHODS: One hundred patients were operated by vertical banded gastroplasty (VBG) and revised with a follow-up of no less than 5 years. Sixty patients were morbidly obese with a body mass index (BMI) of between 40 and 50 kg/m2, and 40 were super-obese with a BMI of >50 kg/m2. Follow-up included 93 patients (93%). RESULTS: Initial surgical mortality was nil. Twenty-five patients required surgery for complications related to the technique (25%) and one patient died due to pulmonary embolism after a re-stapling operation. The percentage excess weight loss was 54.3%, and the BMI was 33 kg/m2 for the 84 patients followed to 5 years post VBG. Only 40 out of 92 patients (43.5%), obtained the weight loss benefit due to the operation. None of them is able to eat a regular diet, and the quality of food intake has been severely affected in some of them. CONCLUSIONS: VBG is, in our experience, a safe and technically simple operation, but the long-term results are questionable. The reoperation rate was high, and weight loss and quality of life are superior with other operations.