The SMART-ALPPS Protocol: Strategy to Minimize ALPPS Risks by Targeting Invasiveness.

BACKGROUND: The range of procedures with documented feasibility by laparoscopic approach is widening in the setting of liver resections. Many technical limits have been overcome in the attempt to reduce the biological impact of major procedures [1-8]. Similarly, associated liver partition and portal vein ligation for staged hepatectomy (ALPPS)-which could be assumed as the paradigm of maxi-invasiveness-has recently been proposed in a minimally invasive fashion to reduce the impact of this procedure [9-12]. Technical insights to perform laparoscopic ALPPS are provided. METHODS: Perioperative and intraoperative tips for laparoscopic ALPPS are provided within a SMART (Strategy to Minimize ALPPS Risks by Targeting invasiveness) protocol. Stage 1: After volumetric and functional assessment, partial liver transection is performed, keeping intact both the hilum and the caval plane (to prevent adhesions), therefore avoiding portal ligation. No inert material is left inside the abdominal cavity at the end of procedure to keep the liver surfaces apart. Radiologic portography with portal vein embolization is scheduled on postoperative day (POD) 1. Liver volume (pre-PVE: 29%; post-PVE: 52%) and liver function measured through a Technetium-99 hepatobiliary scintigraphy [13] (pre-PVE: 2.15%/min/sqm; post-PVE: 3.67%/min/sqm) of the future remnant liver are reassessed within 10 days to verify whether size and function are adequate. Stage 2: After 2 weeks from the first stage, laparoscopic right hepatectomy is performed following an anterior approach. RESULTS: No conversion to open was required. Operative time was 100 and 300 minutes for stage 1 and 2, respectively. Intraoperative blood loss was 50 and 300 ml for the two procedures. Postoperative course was uneventful; patient was discharged on POD 6 of the second operation. CONCLUSIONS: The implementation of a perioperative protocol to prevent the risk of liver failure by both assessing volume and function of FLR and targeting the invasiveness of the surgical procedure may allow to minimize and control risks of a maximally invasive procedure, such as ALPPS.

Determinants of High Parathyroid Hormone Levels in Patients With Severe Obesity and Their Relationship With the Cardiometabolic Risk Factors, Before and After a Laparoscopic Sleeve Gastrectomy Intervention.

BACKGROUND: Obesity is a risk factor for vitamin D deficiency and hyperparathyroidism. Hyperparathyroidism could exert a negative effect on glucose metabolism and vascular function. The aim of this study was to identify the determinants of hyperparathyroidism beyond vitamin D deficiency, whether hyperparathyroidism could have a negative impact on individual health and whether laparoscopic sleeve gastrectomy (LSG) negatively affects the levels of intact parathyroid hormone (iPTH) and 25(OH) vitamin D (25(OH)D). METHODS: We evaluated the levels of iPTH, 25(OH)D, and leptin, together with markers of insulin sensitivity and early cardiovascular disease, in a cohort of 160 patients with severe obesity before and after an LSG intervention. RESULTS: Ninety-seven percent of subjects had vitamin D deficiency, and 72% of them had hyperparathyroidism. After correcting for possible confounders, we found a correlation between iPTH levels and carotid intima-media thickness, as well as with the HOMA index. After the LSG, 25(OH)D levels were significantly increased, while iPTH levels were significantly reduced. The reduction of iPTH was significantly correlated with the reduction of BMI, diastolic blood pressure, and leptin, which was the independent predictor of iPTH reduction. CONCLUSIONS: Our results suggest that vitamin D deficiency is not the sole determinant of hyperparathyroidism in severe obesity because visceral fat deposition and leptin could both play a role. Obesity-related hyperparathyroidism is associated with insulin resistance and atherosclerosis, although the results from previous studies were conflicting. Finally, LSG intervention does not negatively affect vitamin D status and improves hyperparathyroidism.

Occupational low-level exposure to hard metals: cobalt and tungsten biomonitoring as an effective tool to evaluate the effectiveness of industrial hygiene interventions for risk management.

Purpose: The aim of the study was to assess the exposure to Cobalt (Co) and Tungsten (W) in a group of hard metal tool sharpeners through a combined approach of air and biological monitoring, and to evaluate the effectiveness of a control and improvement intervention carried out in collaboration with the medical officers of the local Health Protection Agency, by biomonitoring.Methods: We enrolled 132 workers from 17 companies of the province of Brescia, northern Italy. The study was performed in two phases: (1) an environmental and biomonitoring survey to assess the workers' exposure to Co and W at their usual working conditions; (2) a further biomonitoring survey 3 months after the enforcement of a control and improvement intervention, to assess its effectiveness.Results: Workers were found to be exposed to low concentration of airborne dust containing Co and W but after the intervention we recorded a significant decrease of the urinary concentrations of both Co and W. The extent of the decrease was correlated to the number of preventive industrial hygiene interventions that were carried out.Conclusions: Biological monitoring of Co and W in the hard metal tools manufacturing industry is a sensitive and effective method to evaluate the effectiveness of prevention practices.

Theory of Relativity for Posterosuperior Segments of the Liver.

BACKGROUND: The accessibility to posterosuperior segments of the liver has traditionally constituted a restrain to adopt the laparoscopic approach in this setting. To overcome this challenge, multiple approaches have been reported in literature. Total transabdominal approach has been previously described for this purpose, even though the rationale to standardly adopt it and a technical depiction of how to achieve an optimal mobilization has never been specifically addressed. METHODS: Total transabdominal purely laparoscopic approach to posterosuperior segments of the liver is presented, with detailed emphasis to the rotational motions targeted in laparoscopy. A literature review is presented to summarize all other possible accesses to posterosuperior area of the liver. The institutional series for the laparoscopic approach to Sg 7, Sg 6+7, and Sg8 is retrospectively described. RESULTS: Three rotational motions of the liver are specifically addressed in a video presentation and described for the laparoscopic total-transabdominal approach; the local institutional series using this approach is presented. Other miscellaneous approaches identified from literature encompassing variations in operative position, transabdominal, transthoracic, and combined approaches are described. CONCLUSIONS: Complete mobilization of the ligaments of the liver leads to a rotation of the transection line in front of the operator's view, allowing to achieve a safe total trans-abdominal laparoscopic approach to the posterosuperior ligaments of the liver, without compromising the vascular inflow control, the possibility to convert to open approach, nor requiring potentially harmful decubitus.

Tips and Tricks for a Laparoscopic Approach to Paracaval Liver Segments.

BACKGROUND: A dramatic spread of laparoscopic liver surgery has been experienced over the last years. The approach to paracaval liver segments 1 and 9 is still poorly described in literature, mainly due to its technical demands. OBJECTIVE: The aim of this article was to introduce a safe and effective approach to paracaval liver segments through laparoscopy. METHODS: A minimally invasive approach to resection of Segments 1 and 9 is presented, and an operative set-up is depicted. A step-by-step technique describing the inferior vena cava (IVC) with left and right hepatic venous junction exposure, segmental pedicle isolation, and parenchymal transection is shown through a video document. RESULTS: Postoperative courses were uneventful, and patients were discharged on postoperative day 3. DISCUSSION: The approach to paracaval liver segments requires accurate preoperative case selection, technical, surgical, and anesthesiological expertise in laparoscopic liver surgery, and adequate instrumentary. CONCLUSION: Paracaval segments of the liver can be approached safely through laparoscopy by teams with extensive expertise in the field of laparoscopic liver surgery; however, suspected malignant infiltration of the IVC or unclear preoperative anatomy still contraindicate this approach.

Liver failure in patients treated with chemotherapy for colorectal liver metastases: Role of chronic disease scores in patients undergoing major liver surgery. A case-matched analysis.

AIM: An accurate and noninvasive tool to predict Chemotherapy Associated Liver Injury (CALI) still lacks. Study aimed to evaluate chronic liver disease scores (Aspartate aminotransferase to Platelet Ratio Index, APRI and Fibrosis-4, FIB-4) as Postoperative Liver Failure (PLF) predictors in patients treated with Oxaliplatin for Colorectal Liver Metastases (CLM). METHODS: 8 patients who developed PLF after major hepatectomy (Group B) were compared to 24 patients who did not develop PLF (Group A) in a case-matched analysis for patients and disease characteristics. ROC curves analysis was performed to assess score accuracy. RESULTS: In Group A number of CT cycles was lower, (6 vs 9, p NS), interval between treatment and surgery was longer (11 vs 7 weeks, p < 0.05) and bevacizumab was more frequently administered (66.7% vs 37.5%, p < 0.05). In Group B median APRI score was 0.53 (range: 0.86-4.26) whereas in Group A was 0.30 (range: 0.06-2.21, p < 0.05). Median FIB-4 score was 2.46 (range: 0.86-13.65) in Group B and 1.58 (range: 0.27-7.68) in Group A (p < 0.001). Multivariate analysis showed a significant correlation between APRI and the onset of PLF. A good accuracy of APRI score was evident in ROC curves with an area under the curve of 0.72 (p 0.003). CONCLUSIONS: APRI score is calculated considering both liver damage and platelet count, it is cost effective and easily available. This study demonstrates that there is a good accuracy in PLF prediction and consequently in CT induced liver damage evaluation.

A child with unresectable biliary rhabdomyosarcoma: 48-month disease-free survival after liver transplantation.

We describe here a two-yr-old boy with biliary RMS successfully treated by chemotherapy and LT. The child presented with obstructive jaundice at 20 months of age. A mildly vascularized, non-calcified, partially cystic lesion was visualized in the left hepatic lobe. Solid infiltration of the common bile duct and of both left and right hepatic ducts was suspected. Liver biopsy suggested a botryoid-type embryonal RMS originating from the biliary tract. After extrahepatic spread of the tumor was excluded, a biliary drain was applied and neoadjuvant chemotherapy was started. After the treatment, although reduced in volume, the mass was still unresectable without aggressive surgery and gross residual disease. LT with a reduced segment II/III graft was performed four months after diagnosis. The patient received six cycles of adjuvant chemotherapy, and he is alive and recurrence-free 48 months post-transplantation. A posteriori, the transplant might have possibly been avoided with an aggressive resection with biliary reconstruction. Nevertheless, although the risk of the transplant has to be balanced against the chemoresponsiveness of the tumor, the four-yr disease-free survival of this patient suggests that, when coupled with effective chemotherapy, transplantation might be considered a potential treatment for unresectable biliary RMS.

Bariatric surgery in obesity: changes of glucose and lipid metabolism correlate with changes of fat mass.

BACKGROUND AND AIM: Bariatric surgery induces significant weight loss and improves glucose metabolism in obese patients (BMI>35 kg/m(2)). Our aim was to compare restrictive (LAGB, laparoscopic gastric banding) and malabsorptive approaches (BIBP, biliary-intestinal bypass) on the loss of fat-free mass (FFM), fat mass (FM), and on changes of glucose and lipid metabolism. METHODS AND RESULTS: Body composition (bio-impedance analysis, BIA), blood glucose (BG), insulin, triglycerides, total- and HDL-cholesterol, liver enzymes (AST and ALT) were measured at baseline and 1 year after surgery in patients undergoing LAGB, BIBP, and in diet-treated control patients. In the main study, with patients matched for initial BMI (43-55 kg/m(2), LAGB=24, BIBP=12, controls=6), decreases of BMI, FM, BG and cholesterol were greater in patients with BIBP than with LAGB (p<0.01), while decreases of FFM, insulin, HOMA-IR and triglycerides were similar. No effects on BMI, FM, FFM, BG, insulin, HOMA-IR or cholesterol were observed in the control patients. Decreases of BG, insulin, HOMA-IR, cholesterol and triglycerides correlated with FM but not with FFM decrease. Similar results were obtained in an additional study in patients with a different initial BMI (LAGB=25, BIBP=6, controls=24) and when considering all subjects together. A decrease of liver enzymes (ALT) was greater with LAGB than with BIBP, and HDL-cholesterol increased with LAGB and decreased with BIBP. CONCLUSION: BMI, FM, BG and cholesterol decrease more with malabsorptive than with restrictive surgery, while FFM, insulin, HOMA-IR and triglycerides decrease in a similar way. FFM loss is of low entity. Changes of glucose and lipid metabolism are proportional to a decrease of fat mass but not of fat-free mass.

Effect of weight loss through laparoscopic gastric banding on blood pressure, plasma renin activity and aldosterone levels in morbid obesity.

BACKGROUND AND AIMS: Several mechanisms are probably involved in obesity-related hypertension. This study was aimed to investigate the effect of significant weight loss on blood pressure and plasma renin activity (PRA) and aldosterone levels, other then on metabolic profile, in normotensive and hypertensive obese subjects. METHODS AND RESULTS: Forty hypertensive and 55 normotensive obese subjects were studied under basal conditions and again 1 year after significant weight loss obtained through laparoscopic adjustable gastric banding (LAGB). Weight, waist circumference, blood glucose, insulin, electrolytes (Na and K), lipids and supine and upright PRA and aldosterone were evaluated. All parameters evaluated improved, except for total cholesterol, and electrolytes that did not change. Blood pressure decreased in hypertensive subjects, with a concordant decrease in PRA and supine aldosterone levels, not observed in normotensive patients. CONCLUSION: Weight loss is associated with reduction of blood pressure and of PRA and aldosterone levels in obese hypertensive subjects.

Avaliação da atividade antimicrobiana de extratos vegetais / Evaluation of the antimicrobial activity of vegetal extracts

Especialmente nas últimas décadas, inúmeros esforços têm sido dirigidos para conferir às plantas seu real papel e valor na terapia. Neste estudo foi avaliada a atividade antimicrobiana de extratos secos de Artemisia absinthium L. (losna), Mentha pulegium L. (poejo), Punica granatum L. (romã), Xanthosema violaceum Schott (taioba) e Syzygium cuminii L. (jambolão). Para avaliar a atividade antimicrobiana foi realizado o teste de difusão em ágar, com 15 diferentes microrganismos, utilizando discos impregnados com as dispersões aquosas dos extratos vegetais. A Concentração Inibitória Mínima (CIM) foi determinada para os extratos que apresentaram atividade inibitória. Os resultados mostraram que os extratos de X. violaceum e S. cuminii inibiram, respectivamente, 8 e 6 bactérias. Conclui-se que os extratos de X. violaceum e S. cuminii são capazes de inibir expressivamente o crescimento microbiano.

In the last decades, innumerable efforts have been directed to confer to the plants its real value in the therapy. The aim of this study was to evaluate the antimicrobial activity of dry extracts of Artemisia absinthium L. (wormwood), Mentha pulegium L. (poejo), Punica granatum L. (pomegranate), Xanthosema violaceum Schott(taro) and Syzygium cuminii L. (jambolan). To evaluate the antimicrobial activity the diffusion test in agar was carried through, with 15 different microorganisms, using discs impregnated with aqueous dispersions of the vegetal extracts. For those extracts that had presented inhibitory activity, the calculation of Minimum Inhibitory Concentration was carried out (CIM). The results had shown that the extracts of X. violaceum and S. cuminii had inhibited 8 and 6 bacteria, respectively. What leads to the conclusion that the extracts of X. violaceum and S. cuminii are capable to inhibit the microbial growth.

Obese teenagers treated by Lap-Band System: the Italian experience.

BACKGROUND: Little is known about obesity surgery in young and adolescent patients. The aim of this study is to evaluate results of laparoscopic adjustable gastric banding in obese teenagers. METHODS: Patients < or = 19 years old selected from the database of the Italian Collaborative Study Group for Lap-Band were analyzed according to mortality, comorbidities, laparotomic conversion, intra- and postoperative complications, body mass index (BMI), and % excess weight loss (EWL) at different times of follow-up. Data were expressed as mean +/- SD. RESULTS: Fifty-eight (1.5%) of 3813 patients who underwent operation with the Lap-Band System were < or = 19 years old: 47F/11M; mean age, 17.96 +/- 0.99 years (range, 15-19); mean BMI, 46.1 +/- 6.31 Kg/m2 (range, 34.9 - 69.25); mean % excess weight, 86.4 +/- 27.1 (range, 34 - 226.53). Sixteen (27.5%) of the 58 patients were superobese (BMI > or = 50). In 27/58 (46.5%) patients, 1 or more comorbidities were diagnosed. Mortality was absent. Laparotomic conversion was necessary in 1 patient with gastric perforation on the anterior wall. Overall postoperative complications occurred in 6/58 (10.3%). The band was removed in 6/58 (10.3%) patients for gastric erosion (3 patients), psychologic, intolerance (2 patients), and in the remaining patient was converted 2 years after surgery (BMI 31) to gastric bypass or gastric pouch dilatation. Patient follow-up at 1, 3, 5, and 7 years was 48/52 (92.3%), 37/42 (88.1%), 25/33 (75.7%), and 10/10, respectively. At these times, mean BMI was 35.9 +/- 8.4, 37.8 +/- 11.27, 34.9 +/- 12.2, and 29.7 +/- 5.2 Kg/m2. Mean %EWL at the same time was 45.6 +/- 29.6, 39.7 +/- 29.8, 43.7 +/- 38.1, and 55.6 +/- 29.2. Five/25 (20%) patients had < or = 25% EWL at 5 years follow-up, while none of the 10 patients subject to follow-up at 7 years had < or = 25% EWL. CONCLUSIONS: Lap-Band System is an interesting option for teenagers suffering obesity and its related comorbidities, which deserves further investigation.

Chronic intestinal inflammation and seronegative spondyloarthropathy in children.

BACKGROUND: Spondyloarthropathy in adults has been shown to be associated with either clinical or subclinical intestinal inflammation, however this association has rarely been described in children. AIM: To report paediatric patients primarily referred to a paediatric gastroenterology centre for suspected inflammatory bowel disease and found to be affected by a seronegative spondyloarthropathy. Intestinal inflammatory lesions and rheumatological features have been described in them. SUBJECTS: During a 18-month period, 129 children were referred because of symptoms and signs suggesting an inflammatory bowel disease; 31 of them (range age: 5-17 years) were selected because they also had signs of axial and/or peripheral arthropathy and form the basis of our study. METHODS: The investigated patients underwent ileo-colonoscopy with biopsy and rheumatological assessment that also included X-ray and magnetic resonance imaging of the sacroiliac joints. RESULTS: Only seven children had a classical inflammatory bowel disease (four had ulcerative colitis, three had Crohn's disease), 12 had an indeterminate colitis, 12 a lymphoid nodular hyperplasia of the distal ileum as main feature. In the latter two groups, endoscopy and histology revealed an intestinal inflammation of chronic type distinct from the classical pattern found in inflammatory bowel disease. All were HLA B27 negative and fulfilled the European Spondyloarthropathy Study Group criteria for spondyloarthropathy (except five children classified as undifferentiated spondyloarthropathy). CONCLUSIONS: In a group of children primarily investigated for suspected inflammatory bowel disease and also presenting a seronegative spondyloarthropathy we have described both intestinal and rheumatological features. The majority of them exhibited either an indeterminate colitis or a lymphoid nodular hyperplasia of the distal ileum as main feature. These patients may be a population at risk of developing a full inflammatory bowel disease phenotype.

Comparison between arthroscopy and arthrotomy in the treatment of shoulder instability.

Anterior post-traumatic shoulder instability represents a common finding in orthopaedic surgery. The surgical treatment of this lesion is often indispensable for the normal social life of the patient and for the sports activity of the young. The Bankart procedure with capsular retensioning by arthrotomic access has for years been the gold standard. In the last 10 years arthroscopic accesses have gained more and more consent for the surgical treatment of such lesions, with results that have considerably improved in time. It is the purpose of this study to compare the results obtained in patients affected with anterior-inferior post-traumatic shoulder instability treated by Bankart surgery, arthrotomic and arthroscopic, with a minimum follow-up of 4 years.

Estudo da utilização de antimicrobianos e outros fármacos para distúrbios do trato respiratório em pecientes pediátricos hospitalizados / The study of medication in respiratory and antimicrobian treatment in hospitalized pediatrics patients

O tratamento das doenças respiratórias requerem a utilização de antibióticos, corticosteróides e broncodilatadores. Todavia é desejável que, na pediatria, estas medicações sejam restritas e se utilize uma via de administração confortável. O objetivo deste trabalho foi avaliar a utilização dos medicamentos do trato respiratório e antimicrobianos em pacientes pediátricos hospitalizados, por meio da análise de seus prontuários. Os dados foram coletados durante 120 dias, observando-se os medicamentos prescritos, as doses, as vias de administração e as medidas não farmacológicas prescritas. O critério de inclusão na pesquisa foi estar o paciente internado na pediatria, ter na prescrição um antimicrobiano ou medicamento para o trato respiratório. As análises dos 136 prontuários mostrou que 97,06% continham um antimicrobiano, sendo o mais prescrito ampicilina e o fenoterol e ipratrópio como broncodilatadores. Destaca-se que 21,35% das prescrições apresentaram dosagem abaixo do mínimo e em, 21,89% acima do máximo. Embora em 93,75% dos casos tenha havido prescrição de dieta por via oral, 70,59% dos pacientes tiveram prescrição de medicação por via intravenosa. Esses dados revelam o uso de doses subterapêuticas, prescrição excessiva de antimicrobianos e o uso freqüente da via parenteral que encarecem o tratamento, predispõem ao aparecimento de efeitos indesejáveis como superinfecção, prolongando o tempo de permanência no hospital

Italian Group for Lap-Band System: results of multicenter study on patients with BMI < or =35 kg/m2.

BACKGROUND: The Lap-Band System is the most common bariatric operation world-wide. Current selection criteria do not include patients with BMI < or = 35. We report the Italian multicentre experience with BMI < or = 35 kg/m(2) over the last 5 years. PATIENTS AND METHODS: Data were obtained from 27 centres involved in the Italian Collaborative Study Group for Lap-Band System. Detailed information was collected on a specially created electronic data sheet (MS Access 2000) on patients operated in Italy since January 1996. Items regarding patients with BMI < or = 35 were selected. Data were expressed as mean +/- SD except as otherwise indicated. RESULTS: 225 (6.8%) out of 3,319 Lap-Band patients were recruited from the data-base. 15 patients, previously submitted to another bariatric procedure (BIB =14; VBG= 1) were excluded. 210 patients were eligible for study (34M/176F, mean age 38.19+/-11.8, range 17-66 years, mean BMI 33.9+/-1.1, range 25.1-35 kg/m(2), mean excess weight 29.5+/-7.1, range 8-41). 199 comorbidities were diagnosed preoperatively in 55/210 patients (26.2%). 1 patient (0.4%) (35 F) died 20 months postoperatively from sepsis following perforation of dilated gastric pouch. There were no conversions to laparotomy. Postoperative complications presented in 17/210 patients (8.1%). Follow-up was obtained at 6, 12, 24, 36, 48 and 60 months. At these time periods, mean BMI was 31.1+/-2.15, 29.7+/-2.19, 28.7+/-3.8, 26.7+/-4.3, 27.9+/-3.2, and 28.2+/-0.9 kg/m(2) respectively. Co-morbidities completely resolved 1 year postoperatively in 49/55 patients (89.1%). At 60 months follow-up, only 1 patient (0.4%) has a BMI >30. CONCLUSIONS: Although surgical indications for BMI < or = 35 remain questionable, the Lap-Band in this study demonstrated that all but 1 patient achieved normal weight, and most lost their co-morbidities with a very low mortality rate.

The Italian Group for LAP-BAND: predictive value of initial body mass index for weight loss after 5 years of follow-up.

BACKGROUND: Laparoscopic of the LAP-BAND System placement stage of obesity is a safe operation, but its indication in terms of stage of obesity is controversial. The aim of this study was to evaluate the 5 years stage of obesity results for weight loss in patients with varying preoperative ranges of body mass index (BMI). METHODS: Data were obtained from the Italian Collaborative Study Group for LAP-BAND System (GILB) registry. Detailed information was collected on a specifically created database (MS Access 2000) for patients operated on in Italy from January 1996 to 2003. Patients operated on between January 1996 and December 1997 were allocated to four groups according to preoperative BMI range: 30-39.9 kg/m(2) (group A), 40-49.9 kg/m(2) (group B), 50-59.9 kg/m(2) (group C), and =60 kg/m(2) (group D) percent estimated weight loss respectively. Postoperative complications, mortality, BMI, BMI loss, and (%EWL) were considered in each group. Data are expressed as mean +/- SD, except as otherwise indicated. Statistical analysis was done by means of Fisher's exact test, and p < 0.05 was considered significant. RESULTS: After 5 years from LAP-BAND System surgery, 573 of 3,562 patients were eligible for the study. One hundred fifty-five of 573 (27.0%) were lost to follow-up, 24 of 418 (5.7%) underwent band removal due to complications (gastric pouch dilation, band erosion), eight of 418 (1.9%) were converted to other bariatric procedures, five of 418 (1.2%) died of causes not related to the operation or the band, and 381 of 573 (66.5%) were available for follow-up. Based on 96, 214, 64, and seven patients their preoperative BMI, Were allocated to groups A, B, C, and D, respectively. At time of follow-up mean BMI was 27.5 +/- 5.2 in group A, 31.6 +/- 4.7 in group B, 37.6 +/- 17.3 in group C, and 41.4 +/- 6.9 kg/m(2) in group D. Mean BMI loss was 9.8 +/- 5.4, 12.9 +/- 5.2, 15.8 +/- 8.1, and 23.2 +/- 4.9 kg/m(2), respectively, in groups A, B, C, and D. Mean %EWL at the same time was 54.6 +/- 32.3 in group A, 54.1 +/- 17.2 in group B, 51.6 +/- 35 in group C, and 59.l +/- 17.1 in group D. CONCLUSION: Initial BMI in this series did not correlate with %EWL 5 years after the operation. In fact %EWL was almost the same in each group, independent of preoperative weight. Initial BMI was an accurate indicator of the results obtained 5 years after LAP-BAND in group C (50-59.9 kg/m(2)) and D (=60 kg/m(2)) patients, who remained morbidly obese despite their %EWL.

Ultrasound measurement of visceral and subcutaneous fat in morbidly obese patients before and after laparoscopic adjustable gastric banding: comparison with computerized tomography and with anthropometric measurements.

BACKGROUND: There are now a variety of methods to assess body fat distribution, anthropometric (waist circumference and waist/hip W/H ratio), computed tomography (CT), and ultrasound (US) measurements, with CT considered as the reference method. Bariatric surgery leads to a significant and usually durable weight loss in morbidly obese patients; when assessing its results, it is of interest to measure changes of total fat tissue and of body fat distribution. METHODS: In this study, we compared anthropometric, US, and CT measurements of body fat distribution under basal conditions and 1 year after laparoscopic adjustable gastric banding (LAGB); 120 morbidly obese patients were considered at baseline, and 40 patients were re-evaluated 1 year after LAGB. RESULTS: Thickness of visceral and subcutaneous fat measured through CT and US methods was superimposable both under basal conditions and 1 year after LAGB, and the highest correlation was found between CT and US data on visceral fat, followed by CT and US data on subcutaneous fat; a fair correlation was also found between CT and US data on visceral fat and waist circumference. CONCLUSION: We suggest that evaluation of body fat distribution is accomplished by US instead of CT measurement, because of its lower cost and low exposure risk. Waist circumference stands as a reasonable surrogate of both methods, while W/H ratio is poorly correlated with other measures of body fat distribution.

[Endoscopic percutaneous gastrostomy with gastropexy: a safe technical choice]. / La gastrostomia percutanea endoscopica con gastropessi: una scelta tecnica sicura.

Percutaneous endoscopic gastrostomy is an interesting method of providing enteral nutrition or gastric decompression in patients who are candidates for operative gastrostomy or nasoenteric tube feeding. We report our experience with percutaneous endoscopic gastrostomy with gastropexy (Introducer T-Fastener) in 41 patients. This method uses a technique in which the anterior gastric wall is non-surgically sutured to the anterior abdominal wall before catheter insertion. This technique was successful in all patients, including one subject with a Billroth II hemigastrectomy. Enteral nutrition was started in all cases within 24 hours of the end of the procedure. The medium enteral nutrition period to date is 482.5 days. There were no deaths related to the procedure and no patients had major specific abdominal complications requiring urgent surgical repair. Eight patients complained of minor specific complications which were successfully resolved in all cases with simple conservative procedures and/or therapies. These results indicate that the Introducer T-Fastener method for performing percutaneous endoscopic gastrostomy is rapid, safe, and inexpensive.

Acute administration of nicotine impairs the hypotensive responses to bradykinin in rats.

Nicotine may contribute to smoking-induced endothelial dysfunction because of its ability to impair endothelium-dependent vasodilatation. We investigated whether the acute administration of nicotine changes the hypotensive responses to bradykinin in rats. The effects of pre-treatment with losartan or enalapril on the nicotine-induced changes in the responses to bradykinin were also evaluated. In study 1, anesthetized rats were cannulated via carotid artery for the measurement of mean arterial pressure. Dose-response curves to bradykinin (0.1, 0.4, 1.6, 6.4, 25 and 100 microg/kg) were generated before and 10 min after the injection of nicotine (200 microg/kg, i.v.) or saline. The individual dose-response curves were fitted to a four-parameter logistic equation using the ALLFIT program, which provided an estimate of the maximal response (E(max)) and of the dose of bradykinin producing the half-maximal response (ED(50)). In study 2, rats were pre-treated orally with losartan (10 mg/kg/day) or enalapril maleate (25 mg/kg/day) for 2 weeks. Control rats received tap water alone. After pre-treatment, the rats were anesthetized and used as described in study 1. Nicotine decreased the E(max) (from 73.0+/-7.5 to 65.7+/-3.3 mm Hg; P<0.05) but did not affect the ED(50). In study 2, losartan or enalapril did not affect nicotine-induced decrease in responses to bradykinin; E(max) decreased in both groups (from 68.7+/-6.3 to 62.8+/-4.2 mm Hg, and from 53.8+/-13.0 to 43.1+/-7.1 mm Hg, respectively; P<0.05) without significantly changing the ED(50). These results suggest that nicotine impairs the endothelium-dependent hypotensive responses to bradykinin. This effect is not influenced by inhibition of the angiotensin-converting enzyme or by blockade of the angiotensin AT(1) receptors.