Comparison of short-term outcome of laparoscopic sleeve gastrectomy and gastric bypass in the treatment of morbid obesity: A prospective randomized controlled multicenter SLEEVEPASS study with 6-month follow-up.

BACKGROUND AND AIMS: The long-term efficacy of laparoscopic Roux-en-Y gastric bypass in the treatment of morbid obesity has already been demonstrated. Laparoscopic sleeve gastrectomy has shown promising short-term results, but the long-term efficacy is still unclear. The aim of this prospective randomized multicenter study is to compare the results of Roux-en-Y gastric bypass and sleeve gastrectomy. MATERIAL AND METHODS: A total of 240 morbidly obese patients were randomized to undergo either Roux-en-Y gastric bypass or sleeve gastrectomy. The primary end point of study was weight loss, and the secondary end points were resolution of comorbidities and morbidity. The short-term results at 6 months were analyzed. RESULTS: The mean excess weight loss at 6 months was 49.2% in the sleeve gastrectomy group and 52.9% in the Roux-en-Y gastric bypass group (p = 0.086). Type 2 diabetes was resolved or improved in 84.3% of patients in the sleeve gastrectomy group and 93.3% in the Roux-en-Y gastric bypass group (p = 0.585). The corresponding results for arterial hypertension were 76.8% and 81.9% (p = 0.707) and for hypercholesterolemia 64.1% and 69.0% (p = 0.485). There was no mortality at 6 months. There was one major complication following sleeve gastrectomy and two after Roux-en-Y gastric bypass (p = 0.531). Eight sleeve gastrectomy patients and 11 Roux-en-Y gastric bypass patients had minor complications (p = 0.403). CONCLUSION: The short-term results of sleeve gastrectomy and Roux-en-Y gastric bypass regarding weight loss, resolution of obesity-related comorbidities and complications were not different at 6 months.

The consequences of long-time arm morbidity in node-negative breast cancer patients with sentinel node biopsy or axillary clearance.

BACKGROUND: The aim was to evaluate long-time morbidity in breast cancer patients 3 years after sentinel node biopsy (SNB) or axillary clearance (AC) emphasizing the consequences of morbidity like work-related events and the need of physiotherapy. PATIENTS AND METHODS: Morbidity was evaluated in 92 breast cancer patients 3 years after SNB only and in 47 patients after AC using a questionnaire. The circumferences of the upper extremities and the range of the shoulder movements were also measured. RESULTS: Two SNB and eight AC patients were not able to use the ipsilateral upper extremity to former extent P < 0.005. One SNB and one AC patient were retired or on a long-time sick leave because of arm morbidity. Clinically apparent upper extremity lymphoedema was observed in one SNB patient and in six AC patients, P < 0.005. Two SNB patients had received manual lymph drainage, one of them because of breast oedema. Seven patients had received manual lymph drainage after AC, three of them wore also compression sleeve, P < 0.05 between AC and SNB. CONCLUSIONS: The risk of remarkable long-time arm morbidity after SNB is minimal. Work-related events seem uncommon due to arm morbidity, regardless of the extent of axillary surgery.

STn and prognosis in breast cancer.

Sialyl-Tn (STn) is a carbohydrate antigen formed by the premature 2-6 sialylation of N-acetylgalactosamine. It belongs to a family of antigens widely expressed in carcinomas but only to a limited degree in normal tissue. The expression of STn has been associated with prognosis in different tumors. In this immunohistochemical study of 218 patients with invasive stage I-III breast cancer, STn was expressed in 39% of the tumors. High expression of STn correlated with estrogen and progesterone hormone receptor negativity (p = 0.0002 and p = 0.0003, respectively), and marginally with large tumor size (p = 0.04), high S-phase fraction (p = 0.04) and aneuploidy (p = 0.04), but not significantly with node status, grade or age. The patients had a median follow-up of 17 years. The breast-cancer-specific survival rate of patients with STn-negative cancers was higher than that of patients with cancers that expressed STn during the first 5 years of the follow-up (p = 0.013), but the difference between the groups decreased during the long-term follow-up. STn expression seems to be a marker for short-term, but not for long-term breast cancer outcome prediction.

p27 expression correlates with short-term, but not with long-term prognosis in breast cancer.

UNLABELLED: New prognostic and predictive factors are needed to adjust more appropriate therapy for individual patients after operation. p27 is a cell cycle regulator, and a low tissue expression of this protein has been shown to correlate with poor prognosis in colorectal, lung, gastric, prostate, and breast cancer. In this study on 197 breast cancer patients with a median follow-up of 17 years, the prognostic value of immunohistochemical p27 expression was evaluated. After 5 years of follow-up patients with a p27 expression in less than 50% of the tumor cells had a significantly lower survival rate than those with an expression above this level (p = 0.01). However, after longer follow-up the difference decreased and was no longer significant at 7 years (p = 0.1) or when the entire follow-up period was examined (p=0.67). Tests for associations showed that a low p27 expression correlated with a high histologic grade, a high S-phase fraction (SPF), an advanced TNM stage and negative hormone receptor status. IN CONCLUSION: Tissue expression of p27 is a significant predictor of 5-year, but not of 10- or 15-year breast cancer specific survival.

HER-2/neu oncogene expression in advanced breast cancer.

Tumor tissue from patients with advanced breast cancer was analyzed for HER-2/neu and p53 expression. The tissue samples from primary tumor and from axillary lymph nodes or distant metastases from 118 breast cancer patients were obtained. Sections from formalin-fixed, paraffin-embedded materials were immunostained for HER-2/neu and p53 oncoprotein expression. Staining results were correlated with survival times and disease-free survival times, flow cytometric synthesis phase fractions, and DNA ploidy. No correlation could be found between HER-2/neu and p53 or any other tested factor, but grade I primary cancers that were positive for HER-2/neu showed a tendency for better outcome. The HER-2/neu staining of the metastases was independent of the staining of the primary tumor. HER-2/neu can be used as a prognostic marker for advanced breast cancer, when the primary tumor is well differentiated.

Expression patterns of biologic markers in small breast cancers and preneoplastic breast lesions.

When does proliferating breast epithelium turn malignant? Single parameter analyses have not answered this question. We have tried to answer this through an analysis of immunohistochemical staining patterns in the following morphologically defined breast lesions: atypical ductal hyperplasia (ADH, 23 cases), papilloma (12 cases), ductal cancer in situ (DCIS, 28 cases), and mammographically detected small primary cancers (34 cases). The seven antibodies used were c-neu, bcl-2, p53, p21, CD44, MIB 1, and FAS. Staining patterns were compared within groups and between groups of lesions. Interesting differences in staining patterns were seen between invasive ductal cancer and invasive lobular cancer: invasive lobular cancer was less p53-positive and more CD44-positive than invasive ductal cancer. We found no common pattern in the different proliferating epithelia to show when they become malignant.

The course of Helicobacter pylori infection after partial gastrectomy for peptic ulcer disease.

BACKGROUND/AIMS: While the number of patients operated on for peptic ulcer disease is decreasing, many underwent surgery before the Helicobacter pylori era. Some of them later develop ulcer relapses. The aim of this study was to evaluate the course of H. pylori infection in the gastric remnant after surgery for peptic ulcer disease. METHODOLOGY: This study included 90 consecutive partial gastrectomy patients, obtained from gastroscopy registers of the Department of Surgery, Helsinki University Central Hospital, between 1985 and 1988, in whom both pre- and postoperative samples were available. All of the patients had undergone partial gastrectomy at some time between 1925 and 1988. The median interval between operation and reference gastroscopy was 5 years. RESULTS: Twenty-three patients had a recurrent ulcer, and an additional six patients had a history of an earlier ulcer recurrence. Preoperative H. Pylori infection (68%) did not correlate significantly with the ulcer recurrence rate. The recurrence rate was higher in patients with Billroth I (BI) (27%) and Billroth II (BII) (33%) reconstructions than in those with a Roux-en-Y type reconstruction (9%, BII vs Roux-en-Y, p = 0.02, BI vs Roux-en-Y, p = 0.12). At the time of reference gastroscopy, the proportion of H. pylori positive patients was 38%. The presence of H. pylori at the time of reference gastroscopy did not correlate with ulcer recurrence. A recurrent. ulcer was more often found in patients with histologically normal gastric mucosa in the stump than in those with H. Pylori infection (35% and 19%, p = 0.25). CONCLUSIONS: A persistent H. pylori infection is frequently seen in the gastric remnant after operation for peptic ulcer disease, but the infection does not seem to cause ulcer relapses in the gastric stump or in the anastamosis.

Helicobacter pylori infection after partial gastrectomy for peptic ulcer and its role in relapsing disease.

OBJECTIVE: To elucidate the role of Helicobacter pylori in relapsing disease after partial gastrectomy for peptic ulcer. DESIGN: Retrospective study of gastroscopies between January 1985 and February 1988. SETTING: Department of Surgery, Helsinki University Central Hospital, Finland. PARTICIPANTS: One hundred and fifty-five patients, who had undergone partial gastrectomy for peptic ulcer disease. MAIN OUTCOME MEASURES: Correlation between clinical and laboratory data, macroscopic findings at gastroscopy and histopathology. RESULTS: At gastroscopy 41 patients showed an ulcer at the site of anastomosis or in the gastric stump and two patients had a history of a previous ulcer recurrence. The median time interval between operation and relapse was 4 years. There was no correlation between ulcer recurrence, sex, age, ABO blood group or other diseases. Smokers and patients using non-steroidal anti-inflammatory drugs (NSAIDs) or alcohol had more relapses, but the difference was not significant. The recurrence rate was higher after Billroth II (BII; 34%) than after Roux-en-Y (14%; P = 0.03) or Billroth I (BI) reconstruction (24%). Giemsa staining demonstrated H. pylori in the gastric stump of 37% of the patients. H. pylori expression was related to age but unrelated to sex, ABO blood group, NSAID use, smoking or alcohol consumption. H. pylori positivity was more common (52%) after BI than after BII (28%; P = 0.04) or Roux-en-Y resection (40%). Recurrent ulcer was more often found in gastric remnants with normal mucosa (36%) than in those with H. pylori-positive gastritis (18%; P = 0.03) or H. pylori-negative gastritis (26%). CONCLUSION: It seems that H. pylori infection plays a minor role in the pathogenesis of ulcer recurrence after partial gastrectomy for peptic ulcer disease. Eradication of H. pylori of the remnant stomach is therefore presumably not effective in preventing ulcer recurrence.

Does Helicobacter pylori in the gastric stump increase the cancer risk after certain reconstruction types?

BACKGROUND: In the intact stomach, Helicobacter pylori associated gastritis is considered to be a risk factor for cancer. After partial gastrectomy increased mucosal cell proliferation associated with chronic bile reflux has been claimed to increase the risk for cancer in the gastric stump, whereas the influence of H. pylori infection is not so clear. MATERIAL AND METHODS: The study was a retrospective study with 130 patients, who had undergone partial gastrectomy for peptic ulcer. The cell proliferation rate was determined from immunohistochemical stainings of gastroscopy biopsies with Ki-67 antibodies from gastric remnants. RESULTS: The mean labelling index (LI) was 30.8%. There was no clear association between H. pylori infection and proliferation rate. A significant difference in proliferation rate was seen between patients with a reconstruction type known to be associated with bile reflux and those with a reconstruction without bile reflux. The difference was small in H. pylori negative patients but strong in those with bile reflux and H. pylori infection. The LI increased with age. Smoking had no significant effect on proliferation whereas use of NSAIDs seemed to inhibit proliferation. CONCLUSIONS: Ki-67 is a convenient method for assessing the proliferation rate of the gastric epithelium. Bile reflux and H. pylori infection seem to have a synergistic effect on cell proliferation in the gastric remnant and may explain the increased risk of cancer after partial gastrectomy.

Duodenal diverticulum at endoscopic retrograde cholangiopancreatography, analysis of 123 patients.

BACKGROUND/AIMS: The aim of this study was to investigate the frequency, clinical characteristics, findings and possible varieties of treatment of duodenal diverticula in Finnish patients diagnosed by endoscopic retrograde cholangiopancreatography. MATERIAL AND METHODS: Among 1735 patients investigated by endoscopic retrograde cholangiopancreatography, there were 123 patients with one or more duodenal diverticula and with sufficient clinical data available for this study. Mean age of the patients was 63 years. The male/female ratio was 61/62. Three hundred twenty age and sex matched patients undergoing ERCP during the same time period, but without duodenal diverticula, served as controls. RESULTS: Sixty-one percent of the diverticula were juxtapapillary. Pain and jaundice were the symptoms indicating ERCP in 62% of patients. Laboratory findings were mostly within normal limits. A hepatic or pancreatic tumor was suspected in twelve patients at ultrasound and computer tomography, and five of them had cancer. In 65 patients, both ducts were cannulated at ERCP. In eleven patients, the finding was normal. There was no significant difference in the incidence of pathologic ERCP findings between the patients with juxtapapillary diverticula and diverticula in other parts of duodenum, except pancreatic duct, which was more frequently abnormal in patients with a non-juxtapapillary diverticulum. The patients with juxtapapillary diverticula had not had previous related complications or operations significantly more often than patients with diverticula in other parts of duodenum. The patients with juxtapapillary diverticula had significantly more often biliary stones at ERCP than control patients and they had idiopathic pancreatitis twice as often as control patients, but the difference was not statistically significant. In three patients, the therapy was directed to the diverticulum and 80 patients had some other treatment. CONCLUSION: These data do not reveal any clear correlation between a juxtapapillary diverticulum and pancreato-biliary disorders. However, common bile duct stones were more often found in patients with a juxtapapillary diverticulum than in controls.

DNA analysis in advanced breast cancer.

DNA flow cytometry is frequently used to determine the aggressiveness of breast cancer at the time of primary treatment. Because its role is not as clear in advanced disease, a retrospective investigation was conducted on 132 breast cancer patients with metastases or a subsequent recurrence of the disease. DNA analysis of 96 primary tumors and 53 metastases was performed. The follow-up time was up to 11 years. The mean DNA index of the primary tumors was 1.4 and the mean S-phase fraction (SPF) was 9.4%; 36.5% of the tumors was diploid. The DNA index did not differ significantly among the different stages, but the SPF was significantly higher in stage III than in stage IV. There was no significant difference in ploidy between the stages. There were no significant differences in DNA index and SPF between the primary tumors of the patients with local or distant metastases. The disease-free interval was independent of DNA index, ploidy, and SPF alone. There was no difference in DNA index, ploidy, or SPF between patients with an early or late relapse. Breast cancer-related mortality after metastasis was independent of ploidy alone. In stage I-II, patients with a low SPF had a significantly higher survival rate than other patients. The same was true in patients with a diploid tumor and a low SPF. When the DNA index, SPF, and ploidy of primary tumors and metastases/recurrences were analyzed, no combination of variables yielding an improved prognosis was found. Therefore, it seems that DNA flow cytometry has limited value in determining the prognosis in a patient with metastases or recurrence.

Prognostic value of Ki-67 immunolabelling in primary operable breast cancer.

The prognostic value of Ki-67 immunohistochemical labelling was evaluated in 327 operable primary carcinomas of the breast. The follow-up time was up to 4 years (mean 2.7 years). The disease-free survival in Ki-67 positive patients was shorter than in Ki-67 negative patients (P < 0.005). By combining the Ki-67 expression with ER receptors and stage, subgroups with a different disease-free survival were identified. In stage II patients there was a significant difference (P < 0.005) in disease-free survival between Ki-67 positive/ER negative and Ki-67 negative/ER positive patients. In node negative patients there was no such difference. The disease-free survival according to different prognostic factors, stage, ER and node status, were separately examined using a Cox's proportional hazards model. ER (P < 0.0001), the Ki-67 (P < 0.02), tumour size (P < 0.0001) and nodal status (P < 0.006) were independent prognostic factors. We conclude that the potential value of Ki-67 labelling for prognostic evaluation of patients with breast carcinoma is good.

Gastric changes in coronary-operated patients with low-dose aspirin.

Low-dose aspirin is widely used in patients operated on for coronary disease as secondary prevention of coronary artery occlusion. The changes caused by aspirin in therapeutic doses to gastric mucosa are well documented, but the effect of long-term low-dose aspirin is not so well known. Forty-six volunteer coronary-operated patients with daily low-dose aspirin were interviewed postoperatively, and an upper gastrointestinal tract endoscopy was performed and biopsy specimens taken 3 months after the operation. The findings were compared with a normal population sample of 358 persons from a study previously published. There were significantly more erosions and ulcers or fresh scars in the study group than in the control population--11 of 46 patients and 24 of 358 patients, respectively. The presence of superficial gastritis was similar. Mostly, the lesions were asymptomatic. History of peptic ulcer disease, use of other ulcerogenic drugs, smoking, and alcohol consumption had no predictive value for acute lesions. In contrast, the lesions were associated with chronic superficial gastritis and Helicobacter pylori infection.

Peptic ulcer bleeding today: risk factors and characteristics of the disease.

This study was undertaken to ascertain whether the modern effective anti-ulcer drugs have had any influence on the natural history of hemorrhagic peptic ulcer disease and other acid-related gastroduodenal bleeding disorders. In the prospective part of the study the anamnestic data of all 73 patients admitted to our hospital with a bleeding ulcer or related disease during the year 1989 were compared with the data of 73 patients subjected to elective upper GI tract endoscopy for abdominal symptoms other than bleeding, paying special attention to potential risk factors. There were no differences in previous ulcer history or operations for ulcer disease between these two groups. Cigarette smoking and coffee consumption were not different, but the bleeders consumed alcohol more often, and, in particular, they used ulcerogenic drugs or other hemorrhagic diathesis-provoking agents significantly more frequently than controls. In the retrospective part of the study these 73 patients were compared with the medical records of all 87 patients admitted to our hospital in 1976 for a bleeding peptic ulcer disease, to ascertain whether introduction of H2-blocking agents had had any influence on the nature of the patient population, characteristics of the disease, and severity of bleeding. The patients had become slightly older, and male preponderance was seen in both groups. The proportion of gastric ulcer had decreased, and duodenal ulcer had increased. In general, the bleeding seemed to become less severe but was more severe among women in both groups. In 1989 almost all patients were treated with H2 antagonists, and seven patients received additional medical therapy (vasopressin, somatostatin, or tranexamic acid).(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic factors associated with survival after breast cancer recurrence.

Factors associated with disease-free interval after the primary treatment and survival after a recurrence of breast cancer were studied in 331 female breast cancer patients treated in 1976-1980. Within five years after the primary treatment, recurrence occurred in 131 patients. The observation time of these patients after recurrence was from few weeks to twelve years. Twenty-nine patients were alive at the end of the follow-up. The average disease-free time was 2 years. The clinical stage of the disease in this material was not significantly associated with the disease-free interval. The median survival time after recurrence was 2.7 years when only breast cancer related deaths were included. Survival was significantly better for patients with primarily stage I disease than for patients with primarily stage II-IV disease. The size of the primary tumour was not significantly associated with survival after recurrence. The patients with loco-regional recurrence survived almost significantly better than those with distant recurrence. The disease-free time correlated positively with survival after a recurrence. The present study confirms the view that breast cancer includes several subgroups with a different type of clinical course.

Long-term survival in male breast cancer.

A total of 42 male breast cancer patients (mean and median age 66 years), were followed up for over 25 years or until death. In 24/42 patients (57%) radical surgery and radiotherapy was carried out, surgery alone in 11 patients (26%), and radiotherapy alone in 3 patients (7%). Of the patients 23 died of mammary cancer, 74% of them in five years after primary treatment; 9% of the patients survived 10 years and 7% for 20 years. If only deaths related to breast cancer were included, the 20-year survival was 45%.

Local management in primary breast cancer. Our experience of 331 cases.

The peroperative exploration of axillary content gave wrong result from the stage of axillary nodes in every fourth case compared with the final result of axillary evacuation. There were no locoregional recurrences in stage I-patients irradiated after mastectomy. In postoperatively irradiated stage II-patients there were locoregional recurrences in 2.5% of cases, which was 1/8 of recurrences of patients not irradiated postoperatively.

Costs and benefits of breast cancer diagnosis.

The data from 456 breast cancer patients treated between 1978 and 1985 were retrospectively analyzed to assess the validity of present methods in the diagnosis of breast cancer. The prices and benefits of the methods and the costs of the combinations were compared. The false negative rate of one single method varied from 11.8 to 20.9 per cent, with two methods the rate was 3.7 to 7.1 per cent, and with three methods 2.5 to 3.9 per cent. With four methods no improvement in the results was noted. As a single method, fine needle aspiration biopsy was the cheapest, but it also had the highest false negative rate. The combination of clinical examination, mammography, and fine needle aspiration biopsy seemed to be the most accurate and reasonable combination for diagnosis.

Mammary skin thickening as a prognostic sign in breast cancer.

It has been claimed that mammary skin oedema measured from mammograms of breast cancer patients is a valuable prognostic sign. To test this finding mammograms of 70 patients were reviewed and the status after a follow-up of five years was clarified. 37% of the patients had thickening over 0.25 mm above the tumour and 20% in the inferior part of the breast regardless of the localization of the tumour. The oedematous thickening of the skin was dependent on the tumour size and depth, but independent of its localization. The thickening did not correlate with involved axillary nodes but correlated with the disease-free interval provided that the thickening was over 1.5 mm above the tumour or over 0.75 mm in the inferior part of the breast.

A suggested follow-up time for breast cancer patients.

The data for this study, consisting of 300 females treated for breast cancer in 1951-1961, were evaluated in order to ascertain when excess mortality from breast cancer disappears and what would be an appropriate follow-up period for investigational purposes. The clinical stages of the patients were classified as follows: 23.3%, stage I; 49%, stage II; 20.3%, stage III and 7.3%, stage IV. Halsted's radical mastectomy was performed in 79.7% of the cases. Every patient was given radiotherapy. Two hundred and ninety-eight patients could be followed until death or up to the present. Forty-five patients (16%) were still alive. The survival rate over a 20-year period for the various stages was as follows: stage I, 46.1%; stage II, 22.7% and stage III, 10.9%. Only 26% of the patients with stage I died of breast cancer, while the respective figures for stage II were 57% and stage III, 70%. The death rate from the cancer diminished with time in every stage especially 10 years after primary treatment. After this the observed survival rate curves were almost parallel with the expected curves. Our data show that for follow-up studies a 5-year follow-up is good and a 10-year follow-up is very good to show the trend in the treatment of breast cancer.