Insurance-mandated preoperative dietary counseling does not improve outcome and increases dropout rates in patients considering gastric bypass surgery for morbid obesity

BACKGROUND: Preoperative dietary counseling (PDC) before bariatric surgery is mandated by a growing number of insurance payers. Their claim is that PDC improves outcomes and postoperative compliance. We compared outcomes of GBP patients undergoing a mandatory 13 weeks of PDC (n = 72) to a contemporaneous group of patients with no such requirement (no-PDC; n = 252) who underwent operation between January 2000 and December 2002. METHODS: The PDC and no-PDC groups were characterized by similar male:female ratios (1:4 vs 1:4.6), mean age (42 years), mean body weight (324 lb vs 309 lb), and mean body mass index (BMI) (52 kg/m2 vs 50 kg/m2). The PDC group had a higher incidence of obstructive sleep apnea compared with the no-PDC group (41% vs 28%; P < .04) but otherwise the two groups had similar incidences of obesity-related comorbidities. The presurgery dropout rate was 50% higher in the PDC group than in the no-PDC group (28% vs 19%; P < .05). RESULTS: At 1 year follow-up, the no-PDC patients had a statistically greater percentage excess weight loss (67% vs 60%; P < .0001), lower BMI (32 vs 35; P < .015), and lower body weight (197 vs 218; P < .01). Resolution of major comorbidities, complication rates, 30-day postoperative mortality, and postoperative compliance with follow-up were similar in the two groups. CONCLUSIONS: The data demonstrate that insurance-mandated PDC is an obstacle to patient access for surgical treatment of severe obesity and has no impact on weight loss outcome or postsurgical compliance. PDC should be abandoned by the insurance industry.     

甲襞微循环监测在嗜铬细胞瘤术前准备中的应用

目的:探讨甲襞微循环监测在嗜铬细胞瘤术前药物准备中的临床意义。方法:采取前瞻性自身对照研究,对20例嗜铬细胞瘤患者术前用竹林胺药物准备前、后,以及术后2~3个月,通过WXT-4型微循环图象计算机分析系统监测甲襞微循环,在微循环形态、血管流态、血管周围的情况三方面共22项指标进行定量分析与t检验。结果:20例患者经药物准备前后,在血管襻清晰度、管襻数、输入支管径、输出支管径、管襻长度、红细胞聚集程度、血色、形态积分、流态积分、总积分这10项微循环指标的统计学检验显示差异均有统计学意义(P<0.05或P>0.01);而手术前后微循环各项指标间差异无统计学意义。结论:甲襞微循环可以较好地反映全身微循环的状况,甲襞微循环监测可作为嗜铬细胞瘤术前准备的一项重要指标应用于临床。     

Predictability of retroperitoneal lymph node metastasis by using clinicopathologic variables in surgically staged endometrial cancer

The purpose of this study was to predict lymphatic involvement in endometrial cancer using clinicopathologic variables of patients treated with surgical staging. Overall, 461 patients treated with an initial surgical staging procedure including complete pelvic-para-aortic lymphadenectomy were included. The mean number of resected lymph nodes was 27 (median 26; range 15-83), and 54 patients (12%) had lymphatic involvement. Of these patients, 32 had only pelvic, 15 had both pelvic and para-aortic, and 7 had isolated para-aortic metastases. In the multivariate analysis, deep myometrial invasion (P= 0.02), lymphvascular space invasion (P= 0.001), positive peritoneal cytology (P= 0.002), and cervical involvement (P= 0.003) predicted retroperitoneal lymph node metastasis (RLN) significantly. Two hundred seventy-four patients (59.4%) had at least one of these poor prognostic factors identified by multivariate analysis. In this patient population, 53 (19.3%) had lymphatic involvement compared to 1 patient in the group of 187 patients with low-risk criteria. Ninety-eight percent of patients with RLN were predicted by this model, and with the advent of accurate diagnostic techniques, 40% of patients could be saved from undergoing lymphadenectomy.     

Preoperative staging of gastrointestinal tumors by endosonography

Summary Intracavitary application of ultrasound was first performed for diagnostic purposes in 1967; since that time, it has been more and more widely used. As far as the gastrointestinal tract is concerned, endoscopically controlled ultrasonic probes provide visualization of the various layers of the intestinal wall. It is therefore possible to describe lesions of the esophagus, stomach, and the rectum with regard to their nature and depth of infiltration. Furthermore, periesophageal and perigastric organs can be visualized. It has become evident that endosonography is particularly important for pretherapeutic staging of tumors of the esophagus, stomach, and rectum. Here prospective comparative studies confirm the superiority of this new diagnostic procedure when compared to the methods available to date.     

微血管密度与淋巴结微转移作为食管癌分期补充参数的探讨

目的探讨食管鳞状细胞癌组织中微血管密度(MVD)及区域淋巴结微转移作为食管癌TNM分期补充参数的可行性和意义。方法取术前未经放或化疗的食管癌手术标本22例,Ⅷ因子相关抗原抗体检测癌组织MVD,区域淋巴结作常规HE染色和抗细胞角蛋白(CK)抗体免疫组化染色,检测区域淋巴结的转移和微转移。结合临床病理特征进行统计分析。结果肿瘤MVD平均值为41.6±14.32。MVD与肿瘤的分化程度、浸润深度、淋巴转移、术后早期复发相关(P<0.05);与年龄、性别、肿瘤大小无关(P>0.05)。CK免疫组化染色使淋巴结阳性率从30.11%提高至42.05%。N0期CK( )患者与N1期患者3年复发、转移率分别为40.0%和42.86%(P>0.05)。结论微血管密度和区域淋巴结微小转移是食管癌的重要预后因素,分别作为食管癌分期T、N因素的补充参数,对预示食管癌预后有重要意义。     

Preoperative Chemotherapy for Colorectal Liver Metastases: Impact on Hepatic Histology and Postoperative Outcome

Some investigators have suggested that preoperative chemotherapy for hepatic colorectal metastases may cause hepatic injury and increase perioperative morbidity and mortality. The objective of the current study was to examine whether treatment with preoperative chemotherapy was associated with hepatic injury of the nontumorous liver and whether such injury, if present, was associated with increased morbidity or mortality after hepatic resection. Two-hundred and twelve eligible patients who underwent hepatic resection for colorectal liver metastases between January 1999 and December 2005 were identified. Data on demographics, clinicopathologic characteristics, and preoperative chemotherapy details were collected and analyzed. The majority of patients received preoperative chemotherapy (n = 153; 72.2%). Chemotherapy consisted of fluoropyrimidine-based regimens: 5-FU monotherapy, 31.6%; irinotecan, 25.9%; and oxaliplatin, 14.6%. Among those patients who received chemotherapy, the type of chemotherapy regimen predicted distinct patterns of liver injury. Oxaliplatin was associated with increased likelihood of grade 3 sinusoidal dilatation (p = 0.017). Steatosis >30% was associated with irinotecan (27.3%) compared with no chemotherapy, 5-FU monotherapy, and oxaliplatin (all p < 0.05). Irinotecan also was associated with steatohepatitis, as two of the three patients with steatohepatitis had received irinotecan preoperatively. Overall, the perioperative complication rate was similar between the no-chemotherapy group (30.5%) and the chemotherapy group (35.3%) (p = 0.79). Preoperative chemotherapy was also not associated with 60-day mortality. In patients with hepatic colorectal metastases, preoperative chemotherapy is associated with hepatic injury in about 20 to 30% of patients. Furthermore, the type of hepatic injury after preoperative chemotherapy was regimen-specific. Presented at the American Hepato-Pancreato-Biliary Association 2006 Annual Meeting, March 11, Miami, Florida.     

Primary carcinoma of gallbladder in Yazd, Iran: A 14-year study (1992–2006)

Aim: To investigate the clinico‐pathological profile and stage of disease at presentation of patients with carcinoma of the gallbladder diagnosed during 1992–2006 in Iran. Methods: During this study period 34 consecutive patients with gallbladder carcinoma were identified using a pathology‐based tumor database. The data extracted for each study patient included their gender, age at diagnosis, signs and symptoms, presence of gallstones and histopathological pattern of the gallbladder carcinoma and the UICC/AJCC TNM staging system was used for labeling the stages of the disease. Results: The median age of the 34 patients studied was 69.50 with most between 61 and 70 years of age. The age range of the men was between 53 and 80 years with a median age of 71.50 years and that of the women was between 33 and 79 years with a median age of 68.50 years. The most common symptom was pain in the right hypochondrium. More women had gallstones (15/34) than men (3/10). Adenocarcinoma was the most common histopathological type (91.18%) with the commonest subtype being papillary (47.06%). Eighteen patients had stage IB and stage IIA (52.94%) carcinomas whereas stages IIB and III were observed in six (17.6%) and seven cases (20.6%), respectively. Only three cases (8.82%) were seen in stage IV. The follow up of gall bladder carcinoma (GBC) patients in this study ranged from 6 to 60 months. However, there was a progressive reduction of patients attending follow‐up oncology clinic, particularly by those who had stages III and IV of the disease. Conclusion: Most patients (52.94%) presented with early disease (stage IB and IIA) which carries a good prognosis. Early detection of GBC and a national consensus for the evidence‐based management of GBC in Iran should be the major components of a strategy aimed at improving therapeutic outcome.     

中国原发性肝癌临床分期预测肝癌肝移植预后的临床研究

目的评价“中国原发性肝癌临床分期”对肝癌肝移植疗效的预测价值。方法对1993年4月至2003年1月我科59例采用肝移植治疗的肝癌病人临床资料进行回顾性分析,按中国原发性肝癌临床分期原则进行分期,比较各期间肝癌肝移植疗效。结果Ⅰb、Ⅱa、Ⅱb、Ⅲa和Ⅲb期移植术后1年生存率分别为83·33%、66·67%、50·00%、35·71%和16·67%,各期间术后累计生存率有统计学差异(P<0·01);Ⅰb~Ⅱb和Ⅲa~Ⅲb期移植术后1年生存率分别为66·67%和25·00%,2年生存率分别为45·71%和25·00%,两组间术后累计生存率有统计学差异(P<0·05)。结论中国原发性肝癌临床分期适用于肝癌肝移植术前分期。     

Diagrammatic recording of head and neck tumours1

The increasing demands of clinical audit have resulted in the need for accurate data collection. The use of tumour maps allows standardization of the records of patients with head and neck cancer, which facilitates collation of data in multicentre studies and makes interdepartmental comparisons more meaningful. The aim of this study was to develop an improved standard set of tumour maps for recording the stage of head and neck tumours. A review of the existing tumour diagrams was performed to identify those anatomical areas that are not adequately represented or where ambiguity exists. The areas where improvements could be made were identified as: (1) the anterior commissure of the larynx; (2) axial and sagittal views of the larynx; (3) the pyriform fossa and cervical oesophagus; (4) the oropharynx and vallecula; (5) the nasal cavity and paranasal sinuses; and (6) cervical nodal involvement. A new set of tumour maps is presented in an attempt to correct some of the limitations of the existing diagrams.     

Retrospective review of the preoperative biliary and gastrointestinal evaluation for gastric bypass surgery

BACKGROUND: The purpose of this study was to analyze the frequency and results of preoperative biliary and gastrointestinal (GI) evaluation of patients undergoing Roux-en-Y gastric bypass (RYGB). METHODS: Retrospective review of the preoperative evaluation of 144 consecutive RYGB patients. RESULTS: Cholecystectomy had already been performed in 43 (30%) patients; 22% of those patients with an intact gallbladder had cholelithiasis. Ten patients (7%) had an upper GI x-ray (UGI), and 94 patients (65%) had an esophagogastroduodenoscopy (EGD). Abnormalities were found in 40% of the UGIs and 84% of the EGDs. A total of 96 patients (67%) were tested for Helicobacter pylori; 11% were positive. Twenty-one patients (15%) underwent preoperative colonoscopy; 48% were abnormal, but most of the abnormalities were not clinically significant. Three patients had barium enema x-ray, which was normal in all cases. CONCLUSIONS: The preoperative biliary and GI evaluation of bariatric surgery patients should include a routine ultrasound of the gallbladder. Routine preoperative EGD will detect a significant number of abnormalities that should be treated, but should rarely alter the bariatric surgical procedure or result in denial of bariatric surgery. Many abnormalities will be asymptomatic. Patients should be routinely screened for H. pylori and, if positive, treated before bariatric surgery. Lower GI evaluation should be performed selectively based on the patient's symptoms, physical findings, and guidelines for colorectal cancer and polyp screening.