The knowledge of Polish medical students about surgical treatment of obesity.

BACKGROUND: Surgical treatment of morbid obesity is becoming an increasingly important approach for the treatment of this condition. However, knowledge about the possibility of surgical procedures among general practitioners is far from satisfactory. The source of the problem might be due to a lack of information about bariatric surgery in university curriculum. METHODS: We assessed the knowledge of students from four Polish medical universities. The survey was conducted among 468 students, in their sixth (final) year of study. The survey included two parts-the first nine questions assessed of the level of the students' knowledge about the methods of surgical treatment of obesity, and the following three questions allowed for an evaluation of the amount of information on metabolic surgery provided to students during surgery courses. RESULTS: The results demonstrate a low level of knowledge on the possibility of applying metabolic surgery to treat morbid obesity. The students themselves expressed a need to improve their knowledge and favorably assessed the proposition of expanding the curriculum to include more information on the subject of metabolic surgery. CONCLUSION: The awareness of surgical treatment for morbid obesity among medical students should be improved. The development of an interesting curriculum that is based on current guidelines should be undertaken.

Basal and postprandial plasma levels of PYY, ghrelin, cholecystokinin, gastrin and insulin in women with moderate and morbid obesity and metabolic syndrome.

Metabolic syndrome (MS), defined as central obesity, hyperinsulinemia, insulin resistance, hypertension, dyslipidemia and glucose intolerance, has been associated with inflammatory biomarkers and cardiovascular diseases. This study was carried out on three groups of women; lean controls, moderately obese with MS (OB-MS) and morbidly obese with MS (MOB-MS). The main objectives were: 1. to analyze the plasma levels of total and acylated ghrelin, peptide YY(3-36) (PYY(3-36)), cholecystokinin (CCK), gastrin and insulin levels under basal conditions and in response to a standard mixed meal, and 2. to elucidate the relationship between the plasma levels of these gut peptides and metabolic syndrome parameters. Plasma levels of the gut hormones were measured by radioimmunoassays at time 0 just before the meal and at 30, 60 and 120 min after a meal ingestion. Traditional lipid profile and high-sensitivity C reactive protein (hs-CRP), the strongest biomarker of inflammation were also determined in OB-MS and MOB-MS. When compared to OB-MS, MOB-MS exhibited much higher anthropometric parameters such as waist circumference, higher fat mass and higher plasma levels of low density lipoprotein-cholesterol (LDL-C) and hs-CRP. Both these obese groups revealed significantly higher values of body mass index (BMI), fat mass, total cholesterol (TC), LDL-C, fasting glucose, fasting insulin, insulin resistance (IR) calculated from homeostatic model assessment (HOMA) and hs-CRP compared to the values recorded in lean subjects. Fasting PYY(3-36) level was lower, while fasting acylated ghrelin was higher in MOB-MS than in OB-MS. Plasma total and acylated ghrelin levels were significantly lower in OB-MS compared to lean women. In MOB-MS women the fasting PYY(3-36) levels were lower compared to lean controls and OB-MS, whilst postprandially in both OB-MS and MOB-MS, it was much lower than in lean women. The fasting plasma levels of total and acylated ghrelin and their postprandial decrease were significantly smaller in both obese groups compared to lean subjects. Plasma hs-CRP levels correlated positively with BMI, waist circumference, fat mass, fasting glucose, HOMA IR and fasting active ghrelin, whilst it negatively correlated with plasma fasting and total ghrelin. Moreover, plasma fasting acylated ghrelin correlated positively with fat mass. Fasting total ghrelin correlated positively with BMI, HDL-C and negatively with HOMA IR. We conclude that MS features of obesity are closely related to fasting and postprandial alterations of concentrations of PYY(3-36), CCK and ghrelin, suggesting that determination of gut hormones controlling food intake might be considered as a valuable tool to assess the progression of MS to comorbidities of obesity.

The progress in bariatric surgery.

Morbid obesity, caused by fat tissue accumulation, is a serial multi-factorial chronic disease, with rapidly increasing prevalence in most countries in the world including Poland. Conservative treatment of morbid obesity is almost always unsatisfactory and that is why several surgical methods have been developed. There are four kind of methods: malabsorbtive procedures; restrictive procedures; malabsorbtive/restrictive procedures and experimental procedures. The development of bariatric surgery goes back to 1952 and since that time it has been evolving dynamically. All the surgical methods have benefits and disadvantages. Presently the introduction of minimally invasive surgical techniques seems to be very safe, efficient and cost-effective in treatment for morbid obesity. New methods are also being evaluated, such as gastric myo-electrical stimulation. Bariatric surgery will still be developing until we understand all the factors responsible for it is origin.

The nasal airway evaluation in morbid obesity.

The aim of the present study was to evaluate objectively the nasal patency in the obese patients. A total of 18 morbidly obese patients were recruited for the study. All of them were surgically treated because of morbid obesity using Bilo-Pancreatic Diversion (BPD) or Laparoscopic Gastric Banding (LGB) methods. The patients were free of nasal abnormalities, such as septum deviation, polyps, nasal concha hypertrophy and paranasal sinus diseases. This group comprised 10 men and 8 women aged from 17 to 54. The mean Body Mass Index (BMI) was 51.6 kg/m(2), ranged from 34.7 to 61.8 kg/m(2). In all of the patients the nasal patency was examined by active anterior rhinomanometry according International Standardization Rhinomanometric Committee using air pressure 75, 100 and 150 dPa. The results were compared to the healthy control group. The correlation between BMI and nasal airflow pressure was also examined. We found that inspiration values for 75, 100 and 150 dPa as well as the expiration values for 100 and 150 dPa in standard method and expiration values for 100 and 150 dPa in Broms method using anterior rhinomanometry in morbidly obese patients were statistically significant higher in comparison with the healthy controls. No statistical significant correlation between BMI of obese patients and the airflow pressure values was found. We conclude that in the morbid obesity the nasal patency is reduced as compared to the healthy controls.

Bariatric surgery in Poland from 1993 to 2003.

Morbid obesity affects about 300, 000 patients in Poland. The number and type of bariatric procedures performed between 1993 and 2003 has been based on data collected from Polish surgeons active in this field. During the years 1993 - 2003, 1285 primary bariatric procedures were performed in total. Amongst these 79.1% were, commonly done as restrictive ones, including vertical banded gastroplasty-76.3%, laparoscopic adjustable gastric banding-17.7% and silastic ring vertical gastroplasty-5.5% and at last non-adjustable gastric band with 0.5%. Less popular are malabsorptive procedures - 20.9%, with Roux-en-Y gastric bypass - 79.1% and biliopancreatic diversion 20.9%. During last year 2003: malabsorptive procedures represented one third of all primary procedures and the laparoscopic approach was utilised in 18 % of operations. 61 revisions were reported. There are only three centres with experience in treating more than 100 patients (one of them treated over 600). Two centres have experience in carrying out bariatric surgery for longer than five years. During 1993 - 1997 216 operations were performed. Between 1998 - 2002: 724 procedures, and during last year 345. Patients were treated during last year in ten surgical departments. The number of morbidly obese patients treated surgically in Poland is increasing, but it is still inadequate to meet the growing demand.

Biliopancreatic diversion in Poland.

Biliopancreatic diversion (BPD) is a bariatric operation of proved efficacy especially in patients with metabolic comorbidities. The aim was to assess the results of BPD in relation to weight loss and coexisting lipid and glucose metabolism disturbances in the Polish population. Between October 2001 and December 2003 57 morbidly obese patients (24 male and 33 female) underwent BPD. Median age was 46 years (range: 17-58) and median body mass index (BMI) was 50.2 kg/m(2) (range: 40.1-73 kg/m(2)). Type 2 diabetes mellitus was observed in 11 patients (19.3%), hypercholesterolaemia in 38 patients (66.7%) and hypertriglyceridaemia in 37 patients (64.9%). Median value of BMI decreased at three months to 40.0 kg/m(2), at six months to 36.7 kg/m(2), and after a year to 32.3 kg/m2. Diabetes was completely resolved in all patients. After six months, triglycerides and cholesterol levels were higher than normal only in one patient. Early specific complications that manifested as seroma and nosocomial pneumonia occurred in 5.3% and 3.5% patients, respectively. The following specific late complications were observed: ulceration of stomach stump (3.4%), anaemia (14.0%), hypoalbuminaemia (8.8%), deterioration of haemorrhoids (15.8). All of above complications were treated conservatively expect two haemorrhoidectomies. One patient died due to myocardial infarction eight months after BPD. Five cases of incisional hernias (8.8%) were found. BPD is an effective bariatric procedure also in the Polish population, resulting not only in weight loss but also in the improvement of lipid and glucose metabolism.

Results of revisional operation following vertical banded gastroplasty performed due to morbid obesity--comparison between restoration of vertical banded gastroplasty and conversion of gastric bypass up to three years.

The aim of this study was to analyse incidence and efficacy of revisional surgery for failed vertical banded gastroplasty among 458 patients who underwent primary surgery between 1993 and 2003. Staple line disruption was diagnosed in 29 patients and was an indication for restoration of gastroplasty in 10 cases and a conversion to Roux-en-Y gastric bypass in 19 patients. In two cases of outlet stenosis the band was exchanged to enlarge the collar. In two cases of psychological intolerance of restriction the band was removed because of refusion by patients the conversion to Roux-en-Y gastric bypass. A substantial weight reduction without statistical differences between restoration and conversion group was recognized. In two patients (20%) after restoration and three patients (15.8%) after conversion we observed weight regain (p=0.57). In cases with removed band weight regained up to its value recorded before surgery. In patients with exchanged band weight was under control. No serious complications were observed. We could conclude that patients with weight regain after vertical banded gastroplasty should be offered conversion to Roux-en-Y gastric bypass. When malabsorption is refused, restoration of vertical banded gastroplasty could be also performed. Both of procedures are technically difficult but safe.

[Plasma oxysterols and vitamin E concentrations and lipid profile in morbidly obese women]. / Stezenie oksycholesteroli i witaminy E a profil lipidowy osocza u kobiet ze skrajna otyloscia.

Morbid obesity (BMI > or = 40 kg/m2) is accompanied by lipid disturbances which may be involved in the increased incidence of atherosclerosis, arterial hypertension and non-insulin-dependent diabetes mellitus. The aim of the study was to assess concentrations of total cholesterol (TC), HDL-cholesterol, LDL-cholesterol, triglycerides (TG), products of cholesterol peroxidation--oxysterols, and the major lipophilic antioxidant--vitamin E, in morbidly obese women without coexisting diseases. The study was performed in 11 morbidly obese women (BMI 42.21 +/- 2.21 kg/m2) and 11 healthy volunteers (BMI 23.0 +/- 2.31 kg/m2). Obese women demonstrated higher concentrations of TG (2.03 +/- 0.78 vs. 0.99 +/- 0.37 mmol/l; p < 0.05), 7-ketocholesterol (7-K) (89.85 +/- 63.03 vs. 41.90 +/- 17.33 ng/ml; p < 0.05) and 7-hydroxycholesterol (7-OH) (456.04 +/- 199.22 vs. 132.37 +/- 53.96 ng/ml; p < 0.05), and lower HDL-cholesterol level (0.74 +/- 0.10 vs. 1.30 +/- +/- 0.17 mmol/l; p < 0.05) compared to the control group, while there were no significant differences between the two groups in concentrations of TC, LDL-cholesterol and vitamin E. Plasma vitamin E/(TC + TG) ratio was lower in obese women (6.42 +/- 2.61 vs. 10.76 +/- 4.57 mumol/mmol; p < 0.05). Tocoferols concentration correlated positively with TG (r = 0.45; p < 0.05) and negatively with 7-OH (r = -0.44; p < 0.05) levels. Moreover, concentration of 7-K correlated positively with the level of HDL (r = 0.54; p < 0.05). In conclusion, despite normal TC and LDL-cholesterol concentrations, there are disturbances in cholesterol peroxidation processes, with the rise in oxysterol levels and the decrease in vitamin E concentration in lipoproteins, which may be involved in the increased incidence of cardiovascular diseases in morbidly obese women.

Breast cancer progression and expression of blood group-related tumor-associated antigens.

There is sufficient evidence that blood group related Lewis antigens are tumor-associated molecules. We have conducted immunohistochemical analysis of the expression of Lewis antigens in breast cancer tissue as an indicator of the degree of malignancy and as a prognostic factor. The studies were performed by examining 43 female patients diagnosed with invasive ductal carcinoma of the breast. Postoperative specimens were stained immunohistochemically using a panel of monoclonal antibodies (MAbs) specific for tumor-associated antigens: sialosyl LewisA, LewisA, LewisB, Lewisx, and LewisY. The aims of the study were to compare the appearance of metastases, degree of cancer stage (pTNM), and its histologic differentiation with the expression of Lewis phenotype. The evaluation of antigen expression was performed quantitatively and independently by two pathologists. Statistical significance was defined by Mann-Whitney test. The presented analysis of Lewis antigens showed higher expression of LeB and LeA (p = 0.03) in patients in stage N2 than in stage N1. The expression of LeB and LeY was higher in patients in stage T4 than in stage T1 (p = 0.02). No differences were observed for histologic differentiation. These data suggest that the expression of sialosyl-LeA and LeB antigens in breast cancer may predict metastases to lymph nodes.

Swedish adjustable gastric band (SAGB) implanted laparoscopically in the treatment of morbid obesity--the first experience in Poland.

Surgical treatment of morbid obesity is a recognized method of proceedings in patients who did not obtain any positive results in conservative therapy. In October and November 1998 laparoscopic implantation of the SAGB was performed among ten morbid obesity patients with mean BMI of 41.9 +/- 3.6 kg/m2. It was the first experience in Poland. In this group we observed also non-insulin dependent diabetes mellitus in five, hyperlipidemia in eight and hypertension in three patients. In this series, there was no mortality and no perioperative morbidity. The mean operation time was 158 +/- 51 min. The mean hospital stay was four days after the operation. Median BMI reduction after four months was 4.7 +/- 1.6 kg/m2. Parallel to the reduction in body weight, there occurred a significant reduction in plasma concentration of glucose (111.0 +/- 38.5 vs. 90.2 +/- 20.8 p < 0.01), total cholesterol (223.8 +/- 42.0 vs. 192.7 +/- 21.3 p < 0.005), and LDL-cholesterol (140.4 +/- 34.0 vs. 121.7 +/- 25.2 p < 0.01). Hypertension was still observed only in one patient. Nowadays laparoscopic gastric banding represents the least invasive surgical treatment of morbid obesity. In our series laparoscopic implantation of SAGB seems to be an effective surgical method for the treatment of obesity. Substantial reduction in body weight was associated with improvement in metabolic control. Absence of mortality and morbidity is one of the main aims in bariatric surgery which was achieved in our study. The results of the present, first in Poland, preliminary study confirm previous observations that gastric banding is an effective treatment of obesity.

[Contemporary methods of treatment of morbid obesity]. / Wspólczesne metody leczenia skrajnej otylosci.

Surgical treatment of morbid obesity appears to be more cost-effective than medical treatment. Moreover many medical treatments fail in the long term especially in cases with BMI > 40 kg/m2. That's why surgical treatment was introduced. Two kinds of procedures, gastric restrictive and gastric bypass, have resulted from these years of clinical investigation. Mentioned above surgical treatment produce efficient weight loss during several months after operations. Weight reduction surgery has been reported to improve several comorbid conditions. Minimal invasive procedures are waiting for randomised studies.

[Rare foreign body in the lumen of the small intestine]. / Niezwykle rzadkie cialo obce w swietle jelita cienkiego.

The pathologic conditions caused by forgotten surgical gauze give rise to many different clinical pictures and are very hazardous for the patient. Such patient are seldom reported in the medical literature, mainly due to legal implications. That's why authors describe a case of surgical gauze forgotten after gynecologist procedure. The interval between the causative operation and the admission in our hospital was 7 months. The tentative diagnosis was jejunal tumor. Definitive diagnosis was made intraoperatively, we find surgical gauze 25 cm x 30 cm of diameter in jejunum with jejuno-jejunal fistula which protect patient against ileus.

[Usefulness of Dallop fascia prosthesis for the closure of recurrent inguinal hernia from intraperitoneal access]. / Przydatnosc protezy powiezi Dallop w zamknieciu nawrotowej przepukliny pachwinowej z dostepu sródotrzewnowego.

Two patients are presented with recurrent inguinal hernias. In view of excessive tissue damage hernial sac adhesions and extensive scar, both hernias were closed from intraperitoneal access, suturing onto the borders of deep inguinal ring doubled leaflets of Dallop fascia. The authors consider this method of hernia closures as recommendable and safe.

[Diagnostic value of the analysis of alpha fetoprotein levels in malignant neoplasms of the digestive system]. / Wartosc diagnostyczna oznaczenia stezenia alfafetoproteiny w nowotworach zlosliwych przewodu pokarmowego.

The concentration of alpha-fetoprotein (AFP) in serum was determined in 58 patients (35 males and 23 females) aged from 38 to 87 years treated surgically for malignant tumours of the digestive tract, including colonic carcinoma in 30, gastric carcinoma in 11, pancreatic carcinoma in 10 and oesophageal carcinoma in 7 cases. In 33 patients the tumour was disseminated (into the liver in 22 cases). On the ground of AFP concentration determinations in 40 patients (19 males and 21 females) aged 22 to 80 years operated on for non-neoplastic abdominal diseases the upper normal range was accepted as 9.42 ng/ml. Raised AFP concentration was found in only patient with advanced pancreatic carcinoma and multiple metastases to the liver and lymph nodes. The study showed that serum AFP level in cases of digestive tract malignancies is of limited diagnostic value.

[The role of arachidonic acid metabolites in the skin]. / Rola metabolitów kwasu arachidonowego w skórze.

The metabolism of the arachidonic acid (AA) in normal skin is presented, and the role of its metabolites (eicosanoids) in pathogenesis of psoriasis is reviewed. Beside, possibility of the treatment of psoriasis by means of fish oil and eicosapentaenoic acid (EPA) is discussed.