Lymph node distribution in patients with remnant gastric cancer.

BACKGROUND: Remnant gastric cancer (RGC) is defined as a carcinoma that develops in the gastric remnant from 5 years after gastrectomy, regardless of the primary gastric disease. The pattern of lymph node dissemination in these patients is not well understood. The present study aims to understand the lymph node distribution of patients with RGC in a single center. METHODS: In a total of 1380 patients with gastric cancer, between 1998 and 2020, 43 patients operated on for RGC were analyzed. The pattern of lymph node dissemination was evaluated based on the number of dissected lymph node stations, the number of positive lymph node stations, the positivity index at each analyzed station, the number of dissected lymph nodes per patient, and the positivity index per lymph node station. RESULTS: A mean of 13.0 ± 8.1 lymph nodes were dissected. The incidence of lymph node involvement by dissected station was higher at Stations 19, 11p, 3, 4sb and 7 (50, 40, 37.5, 36 and 31.7%, respectively). Among the positive dissected stations, Station 3 with 52.2%, 4sb with 39.1% and 4sa with 34.8% were the most affected. CONCLUSION: There was no predilection for lymph node involvement when comparing the lesser and greater gastric curvature. The dissection of Stations 3, 4sb and 4sa is fundamental in surgical treatment with curative purposes. The totalization of gastrectomy with lymphadenectomy of the perigastric and supra-pancreatic stations should be the surgery of choice.

Acoustic radiation force impulse elastography and liver fibrosis risk scores in severe obesity.

OBJECTIVE: Identifying significant fibrosis is crucial to evaluate the prognosis and therapeutic interventions in patients with nonalcoholic fatty liver disease (NAFLD). We assessed the performance of acoustic radiation force impulse (ARFI) elastography, APRI, FIB-4, Forns, NFS and BARD scores in determining liver fibrosis in severe obesity. METHODS: A prospective study included 108 patients undergoing bariatric surgery. Liver biopsy specimens were obtained intraoperatively and classified according to the NAFLD Activity Score. Patients were assessed with serological markers and shear wave velocity of the liver was measured with the Siemens S2000 ultrasound system preoperatively. Optimal cut-off values were determined using the area under the receiver operating characteristic curves (AUROC). RESULTS: In the entire cohort prevalence of NAFLD was 80.6%, steatohepatitis 25.9% and significant fibrosis 19.4%. The best tests for predicting significant fibrosis were FIB-4 and Forns scores (both AUROC 0.78), followed by APRI (AUROC 0.74), NFS (AUROC 0.68), BARD (AUROC 0.64) and ARFI (AUROC 0.62). ARFI elastography was successful in 73% of the patients. Higher body mass index (BMI) correlated with invalid ARFI measurements. In patients with BMI < 42 kg/m2, ARFI showed 92.3% sensitivity and 82,6% specificity for the presence of significant fibrosis, with AUROC 0.86 and cut-off 1.32 m/s. CONCLUSION: FIB-4 and Forns scores were the most accurate for the prediction of significant fibrosis in bariatric patients. Applicability and accuracy of ARFI was limited in individuals with severe obesity. In patients with BMI < 42 kg/m2, ARFI elastography was capable for predicting significant fibrosis with relevant accuracy.

Prevalence and severity of syndrome Z in women with metabolic syndrome on waiting list for bariatric surgery: a cross-sectional study.

BACKGROUND: In recent years, obesity has become one of the most important public health problems in the world, with a growing prevalence in both developed and developing countries. Recent studies show that sleep disturbances, especially obstructive sleep apnoea (OSA) may be a manifestation of metabolic syndrome (MetS). Although the association of OSA with the MetS is largely attributed to obesity, the exact pathophysiological mechanisms and their individual characteristics still need to be identified. This study investigated the prevalence and severity of syndrome Z in obese women with MetS on waiting list for bariatric surgery. METHODS: In this double-center cross-sectional study, female patients aged ≥18 years, stage III severe obesity with MetS, on waiting list for bariatric surgery were recruited. The diagnosis for MetS was made according to the criteria of the national cholesterol education program, adult treatment panel III. Clinical, anthropometric, demographic, biochemistry, and sleep measurements were collected. Correlations between continuous variables with sleep parameters were performed using the Pearson correlation test or Spearman correlation test. RESULTS: The mean age of 83 patients was 44.8 ± 11.2 years and mean BMI was 42.6 ± 8.1 kg/m2. There was a significant correlation between OSA and metabolic score (r = 0.336; P = 0.002), neck circumference (r = 0.218; P = 0.048), basal systolic blood pressure (r = 0.280; P = 0.01), total cholesterol (r = 0.277; P = 0.011) and abdomen circumference (r = 0.284; P = 0.009). The mean values of excessive daytime sleepiness were 10.5 ± 7 demonstrating a value considered normal for its presence. However, a high risk for OSA was observed in practically the entire population. It was observed that the prevalence of Syndrome Z (75.9%) increased significantly according to apnoea hypopnoea index (AHI) (P for trend <0.0000). A prevalence of 27.71% for mild OSA, 20.48% for moderate OSA, and 27.71% for severe OSA was observed. An association of AHI severity with all components of MetS was also observed. CONCLUSIONS: We can conclude that syndrome Z presents a high prevalence in a female population with MetS and a considerable severity according to the presence of OSA. Therefore, patients with MetS should be investigated for the presence of sleep disorders. Trial registration The study has been registered on ClinicalTrials.gov NCT02409160 and followed the standards of The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies.

Minimally invasive surgery for gastric cancer in Brazil: current status and perspectives-a report from the Brazilian Laparoscopic Oncologic Gastrectomy Group (BLOGG).

The minimally invasive surgery for gastric cancer in Brazil has begun about two years after the first laparoscopic gastrectomy (LG) performed by Kitano in Japan, in 1991. Although the report of first surgeries shows the year of 1993, there was no dissemination of the technique until the years 2010. At that time with the improvement of optical devices, laparoscopic instruments and with the publications coming from Asia, several Brazilian surgeons felt encouraged to go to Korea and Japan to learn the standardization of the LG. After that there was a significant increase in that type of surgery, especially after the IRCAD opened a branch in Brazil. The growing interest for the subject led some services to begin their own experience with the LG and, since the beginning, the results were similar with those found in the open surgery. Nevertheless, there were some differences with the papers published initially in Japan and Korea. In those countries, the surgeries were laparoscopic assisted, meaning that, in the majority of cases, the anastomoses were done through a mini-incision in the end of the procedure. In Brazil since the beginning it was performed completely through laparoscopic approach due to the skills acquired by Brazilian surgeons in bariatric surgeries. Another difference was the stage. While in the east the majority of cases were done in T1 patients, in Brazil, probably due to the lack of early cases, the surgeries were done also in advanced cases. The initial experience of Zilberstein et al. revealed low rates of morbidity without mortality. Comparing laparoscopic and open surgery, the group from Barretos/IRCAD showed shorter surgical time (216×255 minutes), earlier oral or enteral feeding and earlier hospital discharge, with a smaller number of harvested lymph nodes (28 in laparoscopic against 33 in open surgery). There was no significant difference regarding morbidity, mortality and reoperation rate. In the first efforts to publish a multicentric study the Brazilian Gastric Cancer Association (BGCA) collected data from three institutions analyzing 148 patients operated from 2006 to 2016. There were 98 subtotal, 48 total and 2 proximal gastrectomies. The anastomoses were totally laparoscopic in 105, laparoscopic assisted in 21, cervical in 2, and 20 open (after conversion). The reconstruction methods were: 142 Roux-en-Y, two Billroth I, and three other types. The conversion rate was 13.5% (20/148). The D2 dissection was performed in 139 patients. The mean number of harvested lymph nodes was 34.4. If we take only the D2 cases the mean number was 39.5. The morbidity rate was 22.3%. The mortality was 2.7%. The stages were: IA-59, IB-14, IIA-11, IIB-15, IIIA-9, IIIB-19, IIIC-11 and stage IV-three cases. Four patients died from the disease and 10 are alive with disease. The participating services have already begun the robotic gastrectomy with satisfactory results. The intention of this group is to begin now a prospective multicentric study to confirm the data already obtained with the retrospective studies.

Sleep study, respiratory mechanics, chemosensitive response and quality of life in morbidly obese patients undergoing bariatric surgery: a prospective, randomized, controlled trial.

BACKGROUND: Obesity is a major public health problem in both developed and developing countries alike and leads to a series of changes in respiratory physiology. There is a strong correlation between obesity and cardiopulmonary sleep disorders. Weight loss among such patients leads to a reduction in these alterations in respiratory physiology, but clinical treatment is not effective for a long period of time. Thus, bariatric surgery is a viable option. METHODS/DESIGN: The present study involves patients with morbid obesity (BMI of 40 kg/m2 or 35 kg/m2 to 39.9 kg/m2 with comorbidities), candidates for bariatric surgery, screened at the Santa Casa de Misericórdia Hospital in the city of Sao Paulo (Brazil). The inclusion criteria are grade III morbid obesity, an indication for bariatric surgery, agreement to participate in the study and a signed term of informed consent. The exclusion criteria are BMI above 55 kg/m2, clinically significant or unstable mental health concerns, an unrealistic postoperative target weight and/or unrealistic expectations of surgical treatment. Bariatric surgery candidates who meet the inclusion criteria will be referred to Santa Casa de Misericórdia Hospital and will be reviewed again 30, 90 and 360 days following surgery. Data collection will involve patient records, personal data collection, objective assessment of HR, BP, neck circumference, chest and abdomen, collection and analysis of clinical preoperative findings, polysomnography, pulmonary function test and a questionnaire on sleepiness. DISCUSSION: This paper describes a randomised controlled trial of morbidly obese patients. Polysomnography, respiratory mechanics, chemosensitive response and quality of life will be assessed in patients undergoing or not undergoing bariatric surgery. TRIAL REGISTRATION: The protocol for this study is registered with the Brazilian Registry of Clinical Trials - ReBEC (RBR-9k9hhv).

[Predictive factors for cholelithiasis in the morbidly obese submitted to Roux-en-Y gastroplasty]. / Fatores preditivos de colelitíase em obesos mórbidos após astroplastia em Y de Roux.

OBJECTIVE: This study intended to evaluate predictive factors for cholelithiasis in morbidly obese submitted to gastroplasty with "Y" de Roux reconstruction. METHODS: The population under study was a group of obese patients enrolled in a program of surgical procedure for morbid obesity at the Department of Surgery, College of Medical Sciences, Santa Casa de São Paulo. The exclusion criteria were: patients previously cholecystectomized, patients with diagnosis of pre-operative cholelithiasis and patients with a questionable ultrasonography about existence of billiary stones. A total of 160 patients were operated, 29 with prior cholecystectomy, 23 with pre-operative biliar lithiasis , 5 with questionable ultrasonography about billiary stones and 103 with normal gallbladders at abdominal ultrasonography. RESULTS: Results showed that (46.6%) of patients developed cholelithiasis, 22 of them symptomatic. When patients with or without cholelithiasis were compared, no significant difference related to age, gender and preoperative weight was observed. The body mass index, the triglycerides serum levels, total cholesterol and the fractions HDL-cholesterol and LDL-cholesterol were higher in the group who developed cholelithiasis compared to patients without gallstones and this difference was statistically significant. The percentage of weight loss in the 6th and 12th postoperative month was significantly higher in patients who developed billiary stones. CONCLUSION: The study leads to conclude that body mass index, levels of triglycerides, total cholesterol and the fractions LDL and VLDL are predictive factors for cholelithiasis post-gastroplasty with the "Y" de Roux reconstruction.