Haematological indices and haematinic levels after mini gastric bypass: a matched comparison with Roux-en-Y gastric bypass.

Many surgeons believe mini gastric bypass (MGB) is more likely to cause micronutrient malabsorption compared to Roux-en-Y gastric bypass (RYGB). Till date, there is no published study evaluating haematological indices and haematinic levels in patients undergoing MGB and comparing these with a matched cohort of RYGB. Two hundred patients who underwent MGB between October 2012 and October 2015 were matched to 200 patients who underwent RYGB for age, sex, body mass index and time of surgery. We then compared haemoglobin, mean corpuscular volume, iron, ferritin, vitamin B12 and folic acid levels preoperatively and at 6 monthly intervals after surgery until 2 years. The percentage total weight loss was significantly higher in the MGB group compared to the RYGB group at all time points. At 2 years, MGB and RYGB both led to an increase in anaemia rates but the difference was only significant for MGB group. Compared to RYGB, MGB patients were more likely to be anaemic at 2 years, although the difference was not significant statistically (16.6% vs. 12.7%; P value = 0.55). There was a trend for lower iron and folate levels in MGB group compared to RYGB group but the difference was statistically significant at some of the time periods only (significantly lower folate at 6 and 12 months and lower iron at 6 months in the MGB group). MGB leads to a significant increase in anaemia rates in a supplemented cohort. There is a trend towards lower iron and folate levels and higher anaemia rates in MGB group in comparison with RYGB. Larger studies with longer follow-up should evaluate results of MGB with a shorter biliopancreatic limb.

Preoperative endoscopy may reduce the need for revisional surgery for gastro-oesophageal reflux disease following laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy is a safe and effective bariatric operation, but postoperative reflux symptoms can sometimes necessitate revisional surgery. Roux-en-Y gastric bypass is the preferred operation in morbidly obese patients with gastro-oesophageal reflux disease. In 2011, we introduced preoperative endoscopy to assess for hiatus hernia or evidence of oesophagitis in conjunction with an assessment of gastro-oesophageal reflux symptoms for all patients undergoing bariatric surgery with a view to avoid sleeve gastrectomy for these patients. A prospectively maintained database was used to identify patients who underwent sleeve gastrectomy before and after we changed the unit policy. The need for revisional surgery in patients with troublesome gastro-oesophageal reflux disease was examined. Prior to 2011, 130 patients underwent sleeve gastrectomy, and 11 (8.5%) of them required conversion to Roux-en-Y gastric bypass for symptomatic reflux disease. Following the policy change, 284 patients underwent sleeve gastrectomy, and to date, only five (1.8%) have required revisional surgery (p = 0.001). Baseline demographics were comparable between the groups, and average follow-up period was 47 and 33 months, respectively, for each group. Preoperative endoscopy and a detailed clinical history regarding gastro-oesophageal reflux symptoms may improve patient selection for sleeve gastrectomy. Avoiding sleeve gastrectomy in patients with reflux disease and/or hiatus hernia may reduce the incidence of revisional surgery.

Parenteral nutrition for patients with advanced ovarian malignancy.

BACKGROUND: Parenteral nutrition (PN) in patients with disseminated ovarian cancer remains controversial. The role of PN in providing nutrition and improving quality of life is unclear. The present study aimed to determine the pattern of prescribing in a large teaching hospital, and to identify subgroups where the use of PN was justified. METHODS: Sixty-five patients with advanced ovarian carcinoma received PN between January 2002 and May 2008. A retrospective case note review was undertaken to retrieve data on PN prescribing and outcomes in terms of duration of PN provision, complications, and survival. RESULTS: Three subgroups were identified. Group I consisted of 18 (28%) patients who received PN for a median [interquartile range (IQR)] of 5 (2-11) days. The majority of these 18 patients (n = 13, 72%) had disease-related terminal bowel obstruction. Out of 18 of these patients, 17 (95%) had poor performance status. The median (IQR) survival was 12 (6-28) days. Group II consisted of 40 (61%) patients who were re-established on enteral nutrition. The median (IQR) duration of PN administration was 10 (6-17) days. The most common indication of PN was protracted ileus (n = 25, 63%). Out of 40 of these patients, 35 (88%) patients had good performance status. The median (IQR) survival was 264 (96-564) days. The third group of patients required home PN (n = 7, 11%). Four (58%) patients had short bowel syndrome and three (42%) had terminal intestinal obstruction. All of the patients had good performance status. The median (IQR) duration of PN administration and survival was 241 (90-305) days. CONCLUSIONS: Administration of PN appears to be justified in those patients with a good performance status (i.e. patients capable of self-care), which constituted three-quarters of this cohort. In the remaining patients with poor performance status, and particularly those with terminal intestinal obstruction, PN administration was difficult to justify. PN should not be denied based purely on the pathology, although cautious judgment is required to select those who are most likely to benefit.

Dichloroacetate induces apoptosis and cell-cycle arrest in colorectal cancer cells.

BACKGROUND: Cancer cells are highly dependent on glycolysis. Our aim was to determine if switching metabolism from glycolysis towards mitochondrial respiration would reduce growth preferentially in colorectal cancer cells over normal cells, and to examine the underlying mechanisms. METHODS: Representative colorectal cancer and non-cancerous cell lines were treated with dichloroacetate (DCA), an inhibitor of pyruvate dehydrogenase kinase. RESULTS: Dichloroacetate (20 mM) did not reduce growth of non-cancerous cells but caused significant decrease in cancer cell proliferation (P=0.009), which was associated with apoptosis and G(2) phase cell-cycle arrest. The largest apoptotic effect was evident in metastatic LoVo cells, in which DCA induced up to a ten-fold increase in apoptotic cell counts after 48 h. The most striking G(2) arrest was evident in well-differentiated HT29 cells, in which DCA caused an eight-fold increase in cells in G(2) phase after 48 h. Dichloroacetate reduced lactate levels in growth media and induced dephosphorylation of E1alpha subunit of pyruvate dehydrogenase complex in all cell lines, but the intrinsic mitochondrial membrane potential was reduced in only cancer cells (P=0.04). CONCLUSIONS: Pyruvate dehydrogenase kinase inhibition attenuates glycolysis and facilitates mitochondrial oxidative phosphorylation, leading to reduced growth of colorectal cancer cells but not of non-cancerous cells.