Bone mass decreases in morbidly obese women after long limb-biliopancreatic diversion and marked weight loss without secondary hyperparathyroidism. A physiological adaptation to weight loss?

OBJECTIVE: To investigate the effect of marked weight loss after long limb-biliopancreatic diversion (BPD-LL) on bone mass and serum calcium, 25-OH-vitamin D, and PTH levels in relation to calcium supplementation. BACKGROUND DATA: BPD is the most effective type of bariatric surgery, but it is followed by bone mass loss, mainly attributed to calcium and vitamin D malabsorption leading to secondary hyperparathyroidism. METHODS: Two groups, each consisting of 26 healthy, morbidly obese, premenopausal women, underwent BPD-LL. Both groups received high-calcium diets, 200 IU of vitamin D and 100 mg elemental calcium daily and group B, in addition to an extra 2 g of calcium. Bone density and biochemical markers were measured before and 12 months after BPD-LL. RESULTS: One year after surgery, both groups had lost an average of 55 kg of body weight; albumin-corrected calcium concentration did not change. 25-OH-vitamin D levels in group A were 17.34 +/- 8.90 pre- and 20.51 +/- 14.71 microg/L postoperatively (p = 0.058), and in group B, 15.70 +/- 9.46 and 13.52 +/- 8.16 microg/L (p = 0.489), respectively. PTH levels in group A were 38.5 +/- 12.2 before and 51.2 +/- 32.8 pg/ml after surgery (p = 0.08), and in group B, 48.1 +/- 26.3 and 52.9 +/- 29.2 pg/ml (p = 0.147), respectively. Bone formation markers (alkaline phosphatase, osteocalcin and procollagen type 1), as well as the bone resorption marker CTx, increased significantly in both groups. Bone mineral density T score was 0.862 +/- 0.988 in group A and 0.851 +/- 1.44 in group B and declined postoperatively to -0.123 +/- 1.082 and 0.181 +/- 1.285, respectively. CONCLUSIONS: Marked weight loss after BPD-LL leads to increased bone turnover and normalization of the increased bone mass without calcium or vitamin D malabsorption and without the appearance of secondary hyperparathyroidism. We conclude that the bone mass reduction is a normal adaptation to the decreased loading of the bone following weight loss.

The effect of preoperative chemoradiotherapy on lymph node harvest after total mesorectal excision for rectal cancer.

PURPOSE: This study was designed to evaluate whether preoperative chemoradiotherapy reduces the number of lymph nodes harvested after total mesorectal excision of rectal cancer. METHODS: From January 1995 to December 2007, 168 consecutive patients with rectal cancer underwent total mesorectal excision in the Department of Surgical Oncology at the University of Crete. The patients were divided into three groups (Group A, no chemoradiotherapy; Group B, short course of chemoradiotherapy; Group C, long course of chemoradiotherapy). The primary end points were the number of lymph nodes examined and the percentage of patients with fewer than 12 lymph nodes removed. RESULTS: The overall number of lymph nodes retrieved was not significantly reduced by the use of preoperative chemoradiotherapy. The percentage of patients with fewer than 12 lymph nodes examined, however, was significantly higher in Group C. The leakage rate and the duration of hospital stay were not affected. The rate of wound infections was higher in Group C. CONCLUSION: Preoperative chemoradiotherapy did not significantly decrease the overall number of lymph nodes retrieved but did increase the percentage of patients with fewer than 12 lymph nodes examined.

Anastomotic leakage after low anterior resection for rectal cancer: facts, obscurity, and fiction.

The subject of anastomotic leakage after low anterior resection (LAR) for rectal cancer remains controversial. Risk factors have been discussed in several studies but the findings are often inconclusive. This review evaluates these studies and separates the known risk factors into those that are well documented, those that are obsolete, and those that require further research. We searched the Medline and PubMed databases using the keywords: "leakage," "low anterior resection," "rectal cancer," "risk factors," and their combinations. There were no language or publication year restrictions. References in published papers were also reviewed. Each risk factor was evaluated and discussed separately. The evidence suggests that low anastomoses are more prone to leakage. Other well-documented risk factors are male sex, smoking, and preoperative malnutrition. Routine mobilization of the splenic flexure and the use of a J-pouch seem to reduce the leakage rate. The effect of preoperative chemo-radiotherapy is under scrutiny. The indications for a protective stoma remain debatable. Omentoplasty, bowel preparation, the use of a drain, and tumor stage do not seem to affect the leakage rate. The type of operation (open or laparoscopic) and anastomosis (hand-sewn or stapled) is not crucial.

Sealants after axillary lymph node dissection for breast cancer: good intentions but bad results.

BACKGROUND: This study was conducted to evaluate the effect of 2 surgical sealants on postsurgical drainage and lymphocele formation after axillary surgery for breast cancer. METHODS: This was a prospective, randomized study. Seventy-seven consecutive patients with breast cancer were included and randomized into a control group (18F vacuum drain) and 2 study groups (18F vacuum drain plus COSEAL or BioGlue). RESULTS: The 3 groups were matched. Neither postsurgical drainage nor time to drain removal was affected by the use of either of the 2 sealants. Although no statistically significant difference in lymphocele formation and wound infection was noted, complications caused by intense foreign-body reaction that led to surgical intervention occurred in both study groups. COMMENTS: The use of surgical sealants is not recommended after axillary lymph node dissection for breast cancer. Complications of their use may lead to reoperation.

Towards quality control in rectal cancer surgery: a preliminary Greek experience.

BACKGROUND: The purpose of this study was to evaluate the effect of the introduction of a colorectal unit on provided services for patients with rectal cancer. METHODS: The colorectal unit in our department was initiated in January 2004. A dedicated database was used to retrieve data from 127 consecutive patients who were operated on electively from March 1995 to December 2005. Treatment parameters were compared for patients before (n = 90) and after (n = 37) the introduction of the colorectal unit. RESULTS: In the entire group of patients, 50.3% presented with locally advanced disease (stage III) and 40.9% with tumours located in the lower third of the rectum. A higher preoperative versus postoperative radiotherapy ratio (P < 0.0001), a higher local excision rate (P = 0.04) and a higher low anterior resection to abdominoperineal resection ratio (P = 0.0011) were noted after the initiation of the colorectal unit. In this small series, although parameters like the number of examined lymph nodes, anastomotic leakage rate and distal resection margin improved, they did not reach statistical significance. CONCLUSIONS: The establishment of a colorectal unit seems to have resulted in improved quality of rectal cancer treatment by a dedicated multidisciplinary approach, even after only 2 years of service.

Expression of TNF-superfamily members BAFF and APRIL in breast cancer: immunohistochemical study in 52 invasive ductal breast carcinomas.

BACKGROUND: Recent studies suggest an association between chronic inflammation, modulating the tissue microenvironment, and tumor biology. Tumor environment consists of tumor, stromal and endothelial cells and infiltrating macrophages, T lymphocytes, and dendritic cells, producing an array of cytokines, chemokines and growth factors, accounting for a complex cell interaction and regulation of differentiation, activation, function and survival of tumor and surrounding cells, responsible for tumor progression and spreading or induction of antitumor immune responses and rejection. Tumor Necrosis Factor (TNF) family members (19 ligands and 29 receptors) represent a pleiotropic family of agents, related to a plethora of cellular events from proliferation and differentiation to apoptosis and tumor reduction. Among these members, BAFF and APRIL (CD257 and CD256 respectively) gained an increased interest, in view of their role in cell protection, differentiation and growth, in a number of lymphocyte, epithelial and mesenchymal structures. METHODS: We have assayed by immunohistochemistry 52 human breast cancer biopsies for the expression of BAFF and APRIL and correlated our findings with clinicopathological data and the evolution of the disease. RESULTS: BAFF was ubiquitely expressed in breast carcinoma cells, DCIS, normal-appearing glands and ducts and peritumoral adipocytes. In contrast, APRIL immunoreactive expression was higher in non-malignant as compared to malignant breast structures. APRIL but not BAFF immunoreactivity was higher in N+ tumors, and was inversely related with the grade of the tumors. Neither parameter was related to DFS or the OS of patients. CONCLUSION: Our data show, for the first time, an autocrine secretion of BAFF and APRIL from breast cancer cells, offering new perspectives for their role in neoplastic and normal breast cell biology and offering new perspectives for possible selective intervention in breast cancer.

Erythropoietin and its receptor in breast cancer: correlation with steroid receptors and outcome.

Autocrine/paracrine erythropoietin (EPO) action, promoting cell survival and mediated by its receptor (EPOR) in various solid tumors, including breast carcinoma, questions about the prognostic and therapeutic interest of this system. The expression of EPO/EPOR is steroid dependent in some tissues; however, a clear relationship of EPO/EPOR and steroid receptors in breast cancer has not been established thus far. Recently, the field of steroid receptors has expanded, including rapid effects mediated by membrane-associated receptors, regulating cell survival or apoptosis. The aim of this study was to evaluate EPO/EPOR and membrane-associated steroid receptor expression in breast carcinoma, in view of their prognostic significance, compared with other established markers [estrogen receptor (ER)-progesterone receptor (PR) status and Her2 expression] and hypoxia-induced factor 1 nuclear localization in 61 breast cancer specimens followed for

Increased incidence of papillary thyroid cancer among total thyroidectomies in Crete.

OBJECTIVE: To investigate the increased incidence of papillary thyroid cancer as found in specimens of total thyroidectomies and potential correlation with etiological factors. STUDY DESIGN AND SETTING: A retrospective study on patients who underwent total thyroidectomy, from 1990 to 2004, in an academic tertiary referral medical center. Patients' records were placed in a database, which included medical condition, history, and demographics. Histopathological slides were reviewed with special focus on papillary cancer. RESULTS: Our series consisted of 2379 patients. Thyroid cancer was confirmed in 354 patients (14.88%). Papillary carcinoma represented the most frequent type (316 patients, 89.26%). Increased incidence of papillary carcinomas was noticed after 1995, reaching the maximum value in the year 2000. After 2000, there was a descending trend and then a plateau. CONCLUSION: The increased incidence of papillary thyroid cannot be attributed to dietary patterns or increased diagnostic and therapeutic activity. It is likely to be associated with increased radiation and may be associated with the Chernobyl fallout.