Outcome of laparoscopic gastric bypass in obese and diabetic patients: when surgery fails.

BACKGROUND: The beneficial effects of bariatric surgery on diabetes and obesity have been widely demonstrated in the literature. The aim of our study was to evaluate the rate of failure of laparoscopic gastric bypass both in terms of weight loss and metabolic remission after one follow-up year. METHODS: A longitudinal, multicenter prospective study was carried out on 771 patients affected by pathological obesity. The following parameters were recorded for each patient before surgery: anthropometric, metabolic, social, smoking habits and previous failure of other bariatric procedures. After 1 follow-up year, final weight, final Body Mass Index (BMI), final percentage of lost excess body weight and percentage of lost BMI were evaluated. RESULTS: Statistical analysis showed a correlation between BMI>50 kg/m2, presence of metabolic syndrome, presence of diabetes, gastric pouch volume greater than 60 mL and failure of weight loss outcome. Statistical analysis of metabolic failure has recognized a high preoperative glycated hemoglobin percentage (HbA1c%) value as a statistically significant negative predictive factor. CONCLUSIONS: Bariatric Surgery is the most effective treatment for weight loss and metabolic improvement. However, in our study, surgery did not achieve the expected outcome in patients with specific metabolic, anthropometric and surgical characteristics (BMI>50 kg/m2, presence of metabolic syndrome, presence of T2DM with high preoperative HbA1c% level and gastric pouch volume greater than 60 mL).

Bowel obstruction after cardiac surgery due to diaphragmatic unrecognised hernia.

Diaphragmatic hernia is a very rare occurrence after cardiac surgery without complications. We report a case of a 66-year-old male who underwent double aortocoronary bypass surgery, mitral and tricuspidal annuloplasty developed bowel obstruction 5 months after the operation. X-ray demonstrated small bowel loops in the left side of the chest. A laparoscopy was performed, but during the reduction of the hernia, patient suffered bradycardia because of adhesions between bowel and pericardical sac. Operation was interrupted and patient was transferred to our hospital where a cardiac surgery unit is present. No hemodynamic or respiratory deterioration was observed. Thoracic abdominal entero-CT, transthoracical echocardiography were performed. Patient underwent second surgery in cooperation with the cardial surgical team. Sternotomy was carried out. Hernial content was drawn onto the abdomen, diaphragmatic defect was closed with a direct suture. Mini-laparotomy was performed to exclude that the herniated small bowel did not have ischaemic suffering. No morbidity was observed in the post-operative course. This case illustrates the importance of an accurate pre-operative diagnosis in order to obtain information on relationship between loops of bowel and mediastinal organs. If sternotomy is required, surgical team must be supported by a cardiac surgical team.

Characterization and significance of ACE2 and Mas receptor in human colon adenocarcinoma.

INTRODUCTION: A new arm of the renin-angiotensin system (RAS) has been recently characterized; this includes angiotensin converting enzyme (ACE)2 and angiotensin (Ang)1-7, a heptapeptide acting through the Mas receptor (MasR). Recent studies show that Ang1-7 has an antiproliferative action on lung adenocarcinoma cells. The aim of this study was to characterize RAS expression in human colon adenocarcinoma and to investigate whether Ang1-7 exerts an antiproliferative effect on human colon adenocarcinoma cells. MATERIALS AND METHODS: Gene, protein expression and enzymatic activity of the main components of the RAS were determined on non-neoplastic colon mucosa as well as on the tumor mass and the mucosa taken 5 cm distant from it, both collected from patients with colon adenocarcinoma. Two different human colon cancer cell lines were treated with AngII and Ang1-7. RESULTS: The novel finding of this study was that MasR was significantly upregulated in colon adenocarcinoma compared with non-neoplastic colon mucosa, which showed little or no expression of it. ACE gene expression and enzymatic activity were also increased in the tumors. However, AngII and Ang1-7 did not have any pro-/antiproliferative effects in the cell lines studied. CONCLUSIONS: The data suggest that upregulation of the MasR could be used as a diagnostic marker of colon adenocarcinoma.