Preoperative management of obese patients undergoing bariatric surgery: Role of endoscopy and Helicobacter eradication

BackgroundObesity is a pandemic disease associated to severe health problems. Management is usually multimodal, but many patients eventually need surgery to reduce weight. Many guidelines recommend endoscopy prior to surgery. This study reviews a series of patients undergoing sleeve gastrectomy to see whether endoscopy performance and histopathological findings influence surgery outcome.Material and methodsRetrospective series of patients undergoing sleeve gastrectomy as bariatric procedure at a single institution. We have reviewed the demographic data, the associated pathologies, endoscopic findings prior to surgery, histopathological findings in the surgical resection specimen and postoperative complication rate.Results259 patients fulfilled criteria for the study. Over 70% were women and the mean age was 46.9 (SD 9.8). Preoperative endoscopy was performed in 28.9% of the patients and biopsy only in 19.3%. Helicobacter pylori was detected in 28% of the patients undergoing endoscopy (either in the biopsy or the urease test) and eradicated before surgery in all the patients. Helicobacter pylori was present in 9.7% of the surgical resection specimens and its presence was significantly associated with the development of postoperative complications, mostly staple line leaks (p = 0.01).ConclusionOur study confirms that Helicobacter infection is significantly associated with postoperative complications after sleeve gastrectomy. It is therefore important to detect its presence and eradicate it before surgery.     

A Multidisciplinary,Community-Based Program to Reduce Unplanned Hospital Admissions

ObjectivesTo evaluate the effect of Hospital Admission Risk Program (HARP) on unplanned hospitalization, bed days, and mortality of enrolled individuals and to evaluate the cost-effectiveness of HARP.DesignA retrospective longitudinal analysis of hospital administrative data.InterventionIndividuals at risk of hospitalization were provided with multidisciplinary, community-based care support managed by care coordinators including integrated care planning, education, monitoring, service linkages, and general practitioner liaison over 6-9 months.Setting and ParticipantsIndividuals who were enrolled into 1 of 8 HARP chronic disease management programs between July 1, 2017, and June 30, 2018, at the Royal Melbourne Hospital, Australia.MethodsHospital admissions between 18 months before and 18 months after HARP enrollment were analyzed. Total hospital costs were compared between 18 months before and 12 months after HARP enrollment.ResultsA total of 1553 individuals with a median age of 71 years (interquartile range 60-81), 63.4% males, were admitted to HARP. Both unplanned hospitalizations and bed days were reduced during the HARP intervention compared to within 3 months before enrollment in each of the HARP management programs. After the HARP intervention, cardiac coach, cardiac heart failure, chronic respiratory, diabetes comanagement, and medication management programs had higher hospitalizations and bed days than individuals’ baseline of at least 3 months before HARP enrollment. Individuals in cardiac heart failure and chronic respiratory management programs had a higher mortality rate than other HARP chronic disease management programs. Individuals in cardiac coach, diabetes comanagement, and medication management programs had lower hospital costs during the HARP intervention compared to within 3 months before HARP enrollment.Conclusions and ImplicationsHARP reduced unplanned hospitalization and bed days but did not return individuals’ hospital use to baseline before the intervention. The variations in mortality between HARP chronic disease management programs implies that condition-specific goals between programs is preferable.     

La densidad de los ganglios linfáticos en la linfadenectomía retroperitoneal como marcador novel para predecir la recurrencia en pacientes con cáncer testicular de células germinales: estudio de casos y controles y experiencia clínica a largo plazo de un hospital de referencia terciario

Introduction and objectivesIn this retrospective study, we aimed to evaluate lymph node (LN) density in retroperitoneal lymph node dissection (RPLND) to analyze whether residual mass after chemotherapy might behave as predicting factor for recurrence in patients with germ cell testicular cancer (GCTC).Materials and methodsThe data of 185 patients that were operated between 12/2004 and 02/2017 because of GCTC were reviewed retrospectively. LN density was calculated. The patients were compared statistically in terms of demographic features, tumor characteristics, serum tumor marker levels, treatment strategies, and pathological results according to GCTC subtypes. Correlation analysis was performed to determine the parameters related to recurrent disease.ResultsThe median follow-up was 79 (31-179) months and the median age of the patients was 23 (16-71). The median tumor size was 4 (1-18) cm. Five (2.7%) patients had metastatic disease at initial diagnosis. Seminoma, non-seminomatous-GCT and mix type-GCTC was detected in 62 (33.5%), 60 (32.4%) and 63 (34.1%) patients, respectively. Following inguinal orchiectomy, 48 (25.9%) patients underwent follow-up, 126 (68.1%) patients underwent chemotherapy and 11 (5.9%) patients underwent radiotherapy. A total of 21 (11.4%) patients underwent post-chemotherapy RPLND. Early and late recurrence was seen in 3 (1.6%) and 2 (1.1%) of the patients, respectively. A mild to moderate, negative, but significant correlation was found between the recurrence and the number of LNs containing metastatic deposits and LN density (r= –0.490, P=.024 and r= –0.450, P=.041, respectively).ConclusionsThere was a negative correlation between the number of LNs containing metastatic deposits and LN density and recurrent disease.     

Risk factors for Epstein–Barr virus reactivation after renal transplantation: Results of a large,multi-centre study

Epstein–Barr virus (EBV) reactivation is a very common and potentially lethal complication of renal transplantation. However, its risk factors and effects on transplant outcome are not well known. Here, we have analysed a large, multi-centre cohort (N = 512) in which 18.4% of the patients experienced EBV reactivation during the first post-transplant year. The patients were characterized pre-transplant and two weeks post-transplant by a multi-level biomarker panel. EBV reactivation was episodic for most patients, only 12 patients showed prolonged viraemia for over four months. Pre-transplant EBV shedding and male sex were associated with significantly increased incidence of post-transplant EBV reactivation. Importantly, we also identified a significant association of post-transplant EBV with acute rejection and with decreased haemoglobin levels. No further severe complications associated with EBV, either episodic or chronic, could be detected. Our data suggest that despite relatively frequent EBV reactivation, it had no association with serious complications during the first post-transplantation year. EBV shedding prior to transplantation could be employed as biomarkers for personalized immunosuppressive therapy. In summary, our results support the employed immunosuppressive regimes as relatively safe with regard to EBV. However, long-term studies are paramount to support these conclusions.     

Direct versus indirect transfer for traumatic brain injury to James Cook University Hospital: a retrospective study

IntroductionPatients with traumatic brain injury are referred to the neurosurgical unit at James Cook University Hospital, Middlesbrough, either from local accident and emergency departments (direct transfer from the scene) or from other hospitals (indirect transfer). This study looked at the outcome in both groups.Material and methodsThis was a retrospective observational study using trauma audit research network data for patients treated for traumatic brain injury at the neurosurgery department at the neurosurgical unit at James Cook University Hospital.ResultsA total of 356 patients with traumatic brain injury were admitted under the care of neurosurgeons; 143 (40%) of these patients had a neurosurgical procedure. Of the patients undergoing a neurological procedure, 111 patients were transferred directly while 32 were indirect transfers; 213 patients were managed conservatively. Of those managed conservatively, 165 were transferred directly while 48 were indirect transfers.We compared the length of hospital stay and Glasgow Outcome Scale score for the patients based on whether they were conservatively managed or required surgery in the direct and indirect transfer groups. The difference in the length of stay in the surgical and conservative groups following direct and indirect transfer was insignificant (p = 0.07). The time to the operation in direct and indirect transfer was also not statistically significant (p = 0.06).ConclusionPatients are as safe, if not safer, by reaching the nearest trauma unit with facilities for resuscitation and imaging.     

Persistent extramural vascular invasion positivity on magnetic resonance imaging after neoadjuvant chemoradiotherapy predicts poor outcome in rectal cancer

BackgroundIn rectal cancer, extramural vascular invasion (EMVI) is the presence of tumour cells in blood vessels outside the muscular layer, which is associated with poor prognosis. Regression of EMVI on MRI following neoadjuvant chemoradiotherapy or its persistence may have prognostic implications.MethodsThis retrospective study included 52 patients with rectal cancer who underwent total mesorectal excision following long-course neoadjuvant chemoradiotherapy (CRT). EMVI assessments were done on previous pelvic MRIs obtained before neoadjuvant CRT and eight weeks after the completion of neoadjuvant chemoradiotherapy in initially EMVI positive cases.ResultsPersistently EMVI positive patients had worse overall survival and disease-free survival compared to initially EMVI negative patients and patients who returned to negative (p < 0.001 for both). Multivariate analysis identified persistent EMVI positivity after neoadjuvant treatment (HR, 102.9; p = 0.003) as significant independent predictor of worse overall survival; and persistent EMVI positivity (HR, 17.0; p = 0.002), mesorectal fascia involvement after neoadjuvant treatment (HR, 8.0; p = 0.017), and poor differentiation (HR, 10.3, p = 0.012) as significant independent predictors of worse disease-free survival.ConclusionPersistent EMVI positivity after neoadjuvant therapy appears to be an independent factor for poor overall survival; and persistent EMVI positivity as well as mesorectal fascia involvement on post neoadjuvant therapy MRI and poor differentiation appears to be important predictors of poor disease-free survival in rectal cancer patients.     

Description synthétique des trajectoires des patients insuffisants rénaux chroniques terminaux à partir du registre REIN

Context and objectivesSince 2001, the aim of the REIN registry has been to identify patients suffering from end-stage renal disease and benefiting from replacement therapy in France. The analysis of trajectories aims to evaluate the flow of patients between the different types of treatment in order to better understand and predict patient pathways. The objective of this study was to analyse the incoming and outgoing flows at 1 year of patients prevalent in the REIN registry on 12/31/2017.MethodsFlow analysis was carried out on patients prevalent on 12/31/2017 in the REIN registry by studying the before and after treatment modalities on 12/31/2016 and 12/31/2018. This analysis was initially carried out on all patients, then in sub-groups for each of the 5 treatment modalities.ResultsThe analyses covered 85,472 patients prevalent on 12/31/2017. The overall analysis showed that more than 20% of patients had been diagnosed with end-stage renal disease the year before. Regarding inflow, there was a relative stability for patients treated with self-care hemodialysis, in-center haemodialysis, peritoneal dialysis, and graft, in contrast to patients treated with hemodialysis in a medical unit. Regarding outgoing flows, proportion of deaths at one year was 9%. Peritoneal dialysis was the modality with the highest outflow proportion at one year.ConclusionAnalysis of patients’ trajectories shows variable evolution profiles according to treatment modality and thus could be a valuable tool in the evaluation and improvement of management and care in the field of end-stage renal disease.