Overcoming diabetic gastroparesis en route to kidney transplant.

Gastroparesis is a debilitating condition that affects a significant number of diabetic patients. Some of these patients have end-stage renal disease and are in need of kidney transplant. Symptoms of gastroparesis include: early satiety, pyrosis, epigastric pain, nausea and vomiting, which may lead to caloric and electrolyte deficiencies as well as significant weight loss. A viable option for diabetic gastroparesis patients who fail first line treatments consisting of dietary changes and gastric prokinetic medications is gastric electrical stimulator (GES) implantation. We present a 41-yr-old man and 35-yr-old woman with diabetic gastroparesis, who were initially deemed unacceptable candidates for renal transplantation because of marked malnourishment and a concern that they would not be able to tolerate immunosuppressant medications. In less than two yr following GES implantation, each patient underwent a successful kidney transplant.

Gastric electrical stimulation: a novel treatment for gastroparesis.

Presented herein is a case report of a laparoscopic gastric electrical stimulator implantation for drug-refractory gastroparesis. Technical aspects of the procedure, as well as a review of the existing literature, are discussed. Gastric electrical stimulation offers a new alternative for the treatment of drug-refractory gastroparesis.

Conversion to a laparoscopic biliopancreatic diversion with a duodenal switch for failed laparoscopic adjustable silicone gastric banding.

BACKGROUND: Initial data indicate that long-term weight loss for patients who have undergone laparoscopic adjustable silicone gastric banding (LASGB) may be inadequate. It is anticipated that many of these patients will require revision in the next few years. The procedure of choice for such a revision is unknown. PATIENTS AND METHODS: Two LASGB patients, who underwent a laparoscopic gastric band removal with a conversion to a biliopancreatic diversion with a duodenal switch (BPD/DS), are presented. RESULTS: Their procedures were completed without intraoperative complications. Significant weight loss over 12 and 13 months was achieved. CONCLUSION: The BPD/DS, as opposed to the Roux-en-Y gastric bypass (RGB), is well suited for LASGB revision, as its proximal anastomosis is at the duodenum, away from the gastric band scar tissue. Our experience performing laparoscopic BPD/DS has yielded satisfactory weight loss results without the need for revision.

Laparoscopic reoperative bariatric surgery: experience from 27 consecutive patients.

BACKGROUND: 10 to 25% of patients undergoing bariatric surgery will require a revision, either for unsatisfactory weight loss or for complications. Reoperation is associated with a higher morbidity and has traditionally been done in open fashion. The purpose of this study was to determine the safety and efficacy of reoperative surgery using a laparoscopic approach. METHODS: A retrospective review of medical records over a 22-month period was conducted. 27 consecutive obesity surgery patients, who had undergone a laparoscopic revision, were identified. 26 of the 27 patients were women. The average age was 40.3 years (range 20 to 58 years) and average original preoperative body mass index (BMI) was 51.6 kg/m2 (range 42 to 66.5). The 27 primary bariatric operations consisted of vertical banded gastroplasty (12), gastric band placement (9) and gastric bypass (6). 17 of them were open procedures. After the primary surgery, the lowest average BMI was 37.6 kg/m2 (range 21 to 52), which increased to 42.7 kg/m2 (range 29 to 56) before reoperation. 24 of the 27 reoperations were indicated for insufficient weight loss. On average, revision was undertaken 52 months after the primary procedure (range 12 to 240 months). RESULTS: 24 of the 27 laparoscopic reoperations were conversions to a gastric bypass. A second reoperation was indicated for insufficient weight loss on four occasions. In one case, conversion to open surgery was required. The average operative time was 232 +/- 18.5 minutes (range 120 to 480) and length of hospital stay was 3.7 days (range 1 to 9). 22% percent of patients (6) experienced complications, including pneumothorax, gastric remnant dilation, gastrojejunostomy stenosis, port-site hernia and protein malnutrition. There was no mortality in the study. The average BMI was 35.9 kg/m2 (range 27 to 45.5) 8 months after surgery (range 1 to 22 months). Compared with a preoperative BMI of 42.7 kg/m2, the weight loss was statistically significant (p < 0.001). CONCLUSION: Our results compare favorably with those reported for open reoperative bariatric surgery. A laparoscopic approach may be considered a feasible and safe alternative to an open operation.

Mammographic appearance of nonpalpable breast cancer reflects pathologic characteristics.

OBJECTIVE: To study the relationship of mammographic appearance of nonpalpable breast cancer to the pathologic characteristics. SUMMARY BACKGROUND DATA: The mammographic appearance of nonpalpable breast cancer may be associated with pathologic variables having prognostic significance, which could influence clinical management. METHODS: The authors correlated the mammographic appearance and pathologic characteristics of 543 nonpalpable malignancies diagnosed in a single institution between July 1993 and July 1999. Cancers were divided into four groups based on mammographic presentation: mass, calcification, mass with calcification, and architectural distortion. RESULTS: The majority of masses (95%), masses with calcifications (68%), and architectural distortions (79%) were due to invasive cancers, whereas the majority of calcifications (68%) were due to ductal carcinoma in situ (DCIS). Among invasive cancers, calcifications were associated with more extensive intraductal carcinoma, more Her2/neu immunoreactivity, and more necrosis of DCIS. Lymphatic invasion was more common in cancers presenting as a mass with calcifications. Sixty-nine percent of DCIS associated with invasive cancers presenting as calcifications were of high grade according to the European Organization for Research and Treatment of Cancer. Calcifications in noninvasive tumors were associated with necrosis in DCIS. Two thirds of cancers presenting as architectural distortion had positive margins (65%) compared with 35% to 37% of other mammographic presentations. Mammographic presentation was not significantly related to tumor differentiation or estrogen or progesterone receptor status. The ratio of invasive to noninvasive malignancies increased progressively with increasing age from 1:1 in patients younger than 50 years of age to 3:1 in patients older than 70 years, whereas the proportion presenting as calcifications declined from 63% in patients younger than 50 years to 26% in patients older than 70 years. CONCLUSIONS: Malignancies presenting as calcifications on mammography are most commonly DCIS. When invasive malignancies presented as calcifications, the calcifications were associated with accompanying high-grade DCIS, and the invasive cancers were often Her2/Neu positive. Mammographic masses with calcifications were associated with lymphatic invasion. Excisional biopsy margins were most commonly positive with architectural distortions. The mammographic appearance of nonpalpable malignancies is related to pathologic characteristics with prognostic value, which varies with patient age and influences clinical management.