Impact of reduction mammoplasty on the quality of life of obese patients suffering from symptomatic macromastia: A descriptive cohort study.

BACKGROUND: Although reduction mammoplasty (RM) is an effective and efficient treatment for symptomatic macromastia, overweight and obese patients who request this treatment are frequently rejected because of selection criteria based on the body mass index. Scientific evidence is inconclusive regarding the increased postoperative complications in obese patients undergoing RM, and there is a lack of adequately designed studies examining the impact of RM on the quality of life of this group of patients. PATIENTS AND METHODS: A descriptive cohort study was performed on 37 consecutive obese patients (body mass index > 30 kg/m(2)) undergoing bilateral RM for symptomatic macromastia. Short Form SF-36 quality-of-life questionnaires were completed at interviews a week before surgery and 6 and 18 months after surgery. In addition, 37 women of matching ages, who were companions of patients hospitalized at our short-stay surgery unit, were used as a control group for comparison. Significant differences between repeated measurements on a single sample were assessed using the Wilcoxon signed-rank test. To evaluate these changes, we used effect size by computing Hedges' g corrected. RESULTS: The preoperative SF-36 physical component score was significantly lower than the control group's score (40 vs. 53, p < 0.001). There was no significant difference in the mental component score (45 vs. 49, p = 0.210). Postoperative SF-36 scores were increased with a normalizing effect, as 18 months after surgery only the body pain domain scored lower than the control group scores. CONCLUSIONS: According to our results, obese women with symptomatic macromastia undergoing RM exhibited increased quality of life, and this improvement was maintained over time. THERAPY: Level III Evidence.

The assessment of lymph nodes missed in mesenteric tissue after standard dissection of colorectal cancer specimens.

OBJECTIVE: We studied fresh mesenteric and mesorectal tissue after standard dissection of colorectal cancer specimens using a clearing method to evaluate lymph nodes (LN) that could have been missed. METHOD: After traditional dissection, 50 consecutive unfixed residual mesenteric and mesorectal tissues were entirely managed by a new clearing solution, which incorporates hydrochloric acid obtaining a really good degree of fat dissolution, facilitating the identification of missed LNs. RESULTS: By fat clearance, 498 (mean per specimen, 10) additional LNs were found, most of them (83%) varying in size from 1 to 5 mm. and 22 (4.41%) LNs revealed tumour metastases. In two rectal carcinoma specimens that had been treated by neoadjuvant chemoradiotherapy, no LNs were found by traditional dissection; after checking by the clearing method, additional LNs were harvested in both. Three patients were reclassified and upstaged. CONCLUSION: According to our findings, after standard dissection in the remaining mesentery of colorectal specimen there are missed positive LNs, which should be evaluated to avoid pathological understaging.

Liver transplantation in a case of steatohepatitis and subacute hepatic failure after biliopancreatic diversion for morbid obesity.

BACKGROUND: Biliopancreatic diversion (BPD) was designed to avoid the serious complications of jejunoileal bypass (steatohepatitis and hepatic failure). Although this is today considered a safe and effective procedure, a few reports of patients who developed steatohepatitis and subsequently died in hepatic failure exist. METHODS: We report a morbidity obese patient who developed subacute hepatitis resulting in hepatic failure 1 year after BPD. RESULTS: Because of irreversible liver failure the decision to perform a liver transplantation was made. The patient underwent emergency liver transplant and lengthening of the common limb. The course of liver transplantation and the patient's recovery were uneventful. CONCLUSION: Severe liver disease may rarely follow BPD. Liver transplantation and lengthening of the common bowel may be performed to treat these patients.

Utilidad de los sistemas de información de pacientes para evaluar la calidad en un servicio de cirugía general / Usefulness of patient information systems to evaluate quality in the general surgery service

Se presenta un conjunto de 11 indicadores para evaluar la calidad de determinados componentes del funcionamiento de un Servicio de Cirugía General y Aparato Digestivo. Su elaboración se ha orientado hacia actividades específicas, con la participación activa de un grupo de profesionales de la especialidad, y sobre datos ya existentes en la mayoría de nuestros hospitales. Esta última condición se ha considerado básica para evitar el coste añadido de la implantación de un sistema de información específico, favoreciendo así la viabilidad de los indicadores, y la calidad, consistencia y homogeneidad entre hospitales de los datos que se utilizan en su construcción (AU)

Application of the POSSUM system in bariatric surgery.

BACKGROUND: The POSSUM system has been devised for physiologic and operative scoring. The scoring system produced assessment for morbidity and mortality rates, which did not significantly differ from observed rates. The authors have applied this system to bariatric surgery. PATIENTS AND METHODS: 20 patients were scored by the POSSUM system. All underwent elective bariatric surgery during 1997. All patients were scored at the time of surgery with the physiologic score (FIS) and at discharge with the operative severity score (IQ). The FIS score included age; cardiac signs; chest radiograph; respiratory history; blood pressure; pulse; Glasgow coma score; determinations of hemoglobin, leukocyte, urea, sodium, and potassium levels; and electrocardiogram. The IQ score included multiple procedures, total blood loss, peritoneal soiling, presence of malignancy, and mode of surgery. RESULTS: The mean POSSUM score was 23.9. The mean FIS was 13.95 (12-22), and the mean IQ was 9.4 (7-16). The distribution of patients was performed for BMI. The group with BMI 35-45 (n = 4 patients) had a mean POSSUM score of 22.75, a mean FIS of 13.75, and a mean IQ of 9.0. The group with BMI >45 (n = 16 patients) had a mean POSSUM score of 24.18, a mean FIS of 14.62, and a mean IQ of 9.5. The morbidities were gastric fistula with peritonitis and deep venous thrombosis. The two complications had similar POSSUM scores with different BMIs. No mortality was observed. CONCLUSIONS: According to this experience, the POSSUM scoring system appears to provide an indicator of minor risk of morbidity and mortality in bariatric surgery with vertical banded gastroplasty.

Could the piggyback operation in liver transplantation be routinely used?

OBJECTIVE: To determine if orthotopic liver transplantation with inferior vena cava preservation, performed without using caval cross clamping or venovenous bypass, can minimize hemodynamic instability and low renal perfusion pressure. DESIGN: A prospective case series of 44 consecutive adult orthotopic liver transplantations, with a maximum follow-up of 30 months. SETTING: An institutional university referral center. PATIENTS: Between November 1990 and May 1993, 39 consecutive adult liver transplant recipients underwent transplantation with the following primary diagnoses: alcoholic cirrhosis (n = 23), viral cirrhosis (n = 9), primary biliary cirrhosis (n = 2), Wilson's disease (n = 2), primary sclerosing cholangitis (n = 1), fulminant hepatic failure (n = 1), and secondary hepatic malignant neoplasm (n = 1); five had repeated orthotopic liver transplantation. INTERVENTION: Orthotopic liver transplantations were performed using the piggyback technique, but with placement of the vascular clamp on the inferior vena cava laterally instead of across it so that it remained patent throughout the anhepatic stage. Favorable anatomic conditions in the recipients were not considered; venovenous bypass was not used. MAIN OUTCOME MEASURES: Intraoperative hemodynamic profile, blood loss and replacement, surgical time and complications, and patient survival. RESULTS: No significant hemodynamic changes with lateral clamping and no increases in surgical complications, rate of retransplantation, blood product requirements, or survival rate compared with the standard procedure. CONCLUSION: The piggyback operation could be routinely used in orthotopic liver transplantation.

Colorectal adenocarcinoma: quality of the assessment of lymph node metastases.

PURPOSE: We have studied 193 cases of colorectal adenocarcinoma from a population-based register to determine the minimum number of lymph nodes to be examined to provide an accurate assessment of the presence of nodal metastases. METHODS: The mean total number of lymph nodes identified per surgical specimen was 11 +/- 6.8 (range, 1-36) using traditional dissection. One hundred eighteen specimens (61 percent) were classified as Dukes B. Seventy-five (39 percent) had lymph node metastases (Dukes C) with a mean of 3.3 +/- 4.7 positive lymph nodes per specimen. With binomial distribution we calculate the probability to find at least one positive node in a sample size n with a determined proportion of positive nodes. RESULTS: The error probability in the ganglionar assessment by traditional dissection was 0.05 with 6 examined lymph nodes and 0.01 with 10 examined nodes. CONCLUSION: We must provide the pathologist with a minimum of six examined lymph nodes per surgical specimen for an optimal Dukes B assessment.