Intragastric Balloon as a First Step Before Metabolic Bariatric Surgery in Patients with BMI ≥ 50 kg/m2: are the Results After Balloon Related to Global Outcomes After Surgery?

INTRODUCTION: Patients with body mass index (BMI) ≥ 50 kg/m2, classified with obesity class IV/V, require complex treatments. Intragastric balloon (IGB) is a possible treatment before metabolic bariatric surgery (MBS) that may reduce peri-operative complications. This study evaluates IGB outcomes and complications before MBS in patients with Obesity IV/V, and subsequent MBS results, regarding weight loss and comorbidity resolution. METHODS: Retrospective cohort study of all patients with BMI above 50 kg/m2 submitted to IGB before MBS between 2009 and 2023 in a high-volume center. Variables analyzed included weight loss after IGB and MBS, IGB complications, and comorbidity resolution. Suboptimal clinical responses were defined as %TWL < 5% for IGB, %TWL < 20% for MBS, and %TWL < 25% or BMI ≥ 35 kg/m2 for IGB + MBS. RESULTS: Seventy-four patients (mean BMI 58.8 ± 8 kg/m2) were included. After IGB, the mean %TWL was 14.2 ± 8.5%, with a 21.6% complication rate, predominantly nausea and vomiting, and one death. Suboptimal clinical response of IGB affected 13.5% of patients, and 5.4% required early removal. Two years after MBS, the mean %TWL was 38.2 ± 11.6%, mainly due to MBS, yet approximately one-third of %TWL was attributed to IGB. No correlation was found between IGB and MBS outcomes. At 2-year follow-up, 45.1% patients had %TWL ≥ 25 and BMI < 35 kg/m2. CONCLUSION: The IGB is a treatment option before MBS in patients with Obesity Class IV/V, with acceptable weight loss outcomes but not infrequent complications. A multidisciplinary approach is mandatory, and all treatments must be considered in this difficult subset of patients.

Health-related quality of life 6 years after bariatric surgery: factors influencing outcome.

Bariatric surgery is the only proven treatment to significantly improve obesity and its associated comorbidities. The success of bariatric surgery goes beyond weight lost: quality of life (QoL) is acquiring relevance when evaluating outcomes after bariatric surgery but few studies evaluated factors influencing QoL at long term. The main objective of this study is to identify factors that could affect QoL more than 5 years after bariatric surgery. Methods: We performed an observational study in which we apply "Moorehead-Ardelt Quality of Life Questionnaire" to 94 patients that were submitted to bariatric surgery with more than 5years of follow-up. Patients questionnaire score was compared to several variables: age, sex, main surgical procedures, primary or revisional surgery, complications, weight loss, and improvement of comorbidities (diabetes, dyslipidemia, hypertension, musculoskeletal disorders, and psychiatry pathology). Results: QoL was significantly influenced by weight loss outcomes (%excess weight loss, %total weight loss, and final body mass index). QoL was neither significantly influenced by sex or age, type of surgery nor previously failed bariatric surgeries or complications. Improvement of hypertension was related to increased QoL, but improvement of other associated comorbidities did not had significant impact on patient's QoL at long term. Conclusion: It appears that the main factors influencing long-term QoL after bariatric surgery are related to weight loss outcomes.

Clinical Outcome of Patients Submitted to Liver Resection in the Context of Metastatic Breast Cancer: A Study of a Tertiary Hospital Center.

INTRODUCTION: Breast cancer is the most incident cancer in the world, accounting for 25% of new cancers per year in females. It is the most frequent malignancy in women, being the fifth cause of death from cancer worldwide. Approximately 5 to 10% of patients already present with metastases at diagnosis, and the liver is the site of metastases in half of these cases. Liver metastasis (LM) resection, performed after neoadjuvant systemic treatment, has been reported to increase median overall survival in this population. AIM: The aim of this analysis is to assess the outcomes of patients undergoing breast cancer liver metastasis surgical resection, including impact on survival, compared to patients where metastasectomy was not performed. METHODS: retrospective review of 55 female patients with breast cancer liver metastases, diagnosed and treated in a single tertiary university hospital from January 2011 to December 2016 was performed. RESULTS: In 32/55 patients (58.2%), multi-organ metastases were identified (the most common sites being bone, lungs, and lymph nodes). Of the remaining 23 patients, the liver was the unique metastatic site; thirteen patients had diffuse bilobar hepatic metastases. The remaining ten patients were proposed for surgical treatment; three of them had peritoneal carcinomatosis identified during surgery, and no hepatic metastasectomy was performed. As a result, only seven (12.7%) patients underwent liver metastasectomy. Overall survival was higher in patients who had LM surgery (65 months [Interquartile Range (IQR) 54-120]), in comparison to those diagnosed with diffuse bilobar hepatic metastases (17.5 months [IQR 11-41]), and with those showing concurrent liver and bone metastases (16.5 months [IQR 6-36]) (p = 0.012). In univariable analysis, the latter two groups showed worse overall survival outcomes (Hazard Ratio (HR) = 3.447, 95%CI: 1.218-9.756, p = 0.02 and HR = 3.855, 95% Confidence Interval (CI): 1.475-10.077, p = 0.006, respectively) when compared to patients with LM. CONCLUSION: In our series, patients submitted to metastasectomy had a median overall survival after diagnosis of LM three times greater than the non-operated patients with isolated LM, or concurrent LM and bone metastases (65 vs. 17.5 and 16.5 months, respectively). As is vastly known for colorectal cancer liver metastasis, resection of breast cancer liver metastasis may reduce tumor burden, and therefore may improve patient outcome.

How Far Can Our Expectations Go on Revisional Bariatric Surgery After Failed Adjustable Gastric Banding?

PURPOSE: Bariatric surgery has proven its effectiveness in the treatment of obesity and related comorbidities. However, several procedures may be required to treat this chronic disease and/or complications after bariatric surgery. The most frequent revisional surgeries performed after failed laparoscopic adjustable gastric banding (AGB) have been Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). The aim of this study is to compare medium-term outcomes of primary and revisional bariatric procedures. MATERIAL AND METHODS: Single institution, matched case-control study of obese patients submitted to bariatric surgery, divided into four groups of 50 patients: (A) primary RYGB; (B) primary SG; (C) revisional Roux-en-Y gastric bypass (rRYGB) after failed laparoscopic AGB; (D) revisional sleeve gastrectomy (rSG) after failed laparoscopic AGB. Demographic variables, surgical procedures characteristics and complications, weight loss outcomes and resolution of comorbidities were compared. RESULTS: Mortality and morbidity were comparable between primary and revisional procedures. Weight loss outcomes were inferior in patients submitted to rRYGB when compared to those submitted to RYGB, with no significant differences found when comparing the other groups. Regarding comorbidities' outcomes, only patients submitted to rSG had lower odds of comorbidities' improvement. Patients submitted to rRYGB had an odd 7 times higher of comorbidities' improvement than those submitted to rSG, independent of weight loss outcomes. CONCLUSION: Revisional surgeries are safe procedures with adequate weight loss outcomes in this difficult set of patients. The choice of revisional procedure may not influence weight loss outcomes, but rRYGB seems to be a better option regarding comorbidities' resolution.

Mixed Adenoneuroendocrine Carcinoma Causing Colonic Intussusception.

Colonic intussusception is a rare cause of intestinal obstruction in adults and is caused by a malignant lesion in about 70% of cases. Early diagnosis and treatment are essential. We present a 64-year-old male patient with right colonic intussusception caused by a mixed adenoneuroendocrine carcinoma (MANEC), presenting as a giant pedunculated polyp (54 mm of largest diameter). The patient underwent right colectomy with primary anastomosis and adjuvant chemotherapy. The diagnosis of intussusception of the colon in adults is difficult because of its rarity and nonspecific clinical presentation. In this case, the cause was a rare histological type malignant tumor (MANEC).

Adenoma-carcinoma sequence in intrahepatic cholangiocarcinoma.

INTRODUCTION: Cholangiocarcinoma is a rare tumor but recent data report a worldwide increase in incidence and mortality. There are several risk factors associated with cholangiocarcinoma, and chronic inflammation of billiary tree seems to be implied in the cholangiocarcinogenesis, but little is known about this process. PRESENTATION OF CASE: We present a 56-year-old female with a bile duct adenoma incidentally discovered in the follow up of breast cancer that 18 months later progress to intrahepatic cholangiocarcinoma. DISCUSSION: This is a rare presentation of intrahepatic cholangiocarcinoma that suggests the classic adenoma-carcinoma sequence in cholangiocarcinogenesis. Furthermore this case gives rise to some questions about the possible common ground on intrahepatic cholangiocarcinoma and breast cancer. CONCLUSION: Cholangiocarcinogenesis is a complex multi-step mechanism and further investigations are needed to fully understand this process.