BARIATRIC SURGERY REVERSES METABOLIC RISK IN PATIENTS TREATED IN OUTPATIENT LEVEL

Background

The conventional treatment of obesity presents unsatisfactory results on weight loss and its long-term sustainability, therefore bariatric surgery has been suggested as an effective therapy, determining sustainable long-term weight loss, reversal of components of cardiometabolic risk and improved quality and life expectancy.

Aim

To investigate the clinical component of the cardiometabolic risk in patients undergoing bariatric surgery assisted on outpatient basis.

Methods

The sample consisted of 47 patients with ages between 18 and 60 years, 72% females. Diabetes mellitus, hypertension, and dyslipidemia were prospectively evaluated by using the Assessment of Obesity-Related Co-morbidities scale.

Results

Occurred improvement in these co-morbidities within 12 months after surgery. Co-morbidities resolved were greater than those improved.

Conclusion

The study revealed that the Assessment of Obesity-Related Co-morbidities is a system that can be effectively used to quantify the degree of reduction of the severity of the cardiometabolic risk in response to bariatric surgery.     

COMBINED LIVER-KIDNEY TRANSPLANTATION: EXPERIENCE AT A BRAZILIAN UNIVERSITY HOSPITAL

Background

Combined liver-kidney transplant is a routine procedure in many transplant centers. The increase in its number coincided with the introduction in 2002 of the MELD (Model for End-stage Liver Disease) score for allocation of livers, prioritizing patients with renal dysfunction.

Aim

To analyze the experience with combined liver-kidney transplantation in a liver transplant center in Brazil.

Method

A retrospective review was conducted. All transplants were performed using grafts from deceased donors.

Results

Sixteen combined liver-kidney transplantations were performed in the same period, which corresponds to 2.7% and 2.5% of the kidney and liver transplants, respectively. Fourteen patients were male (87.5 %) and two were female (12.5%). The average patients and donors age was 57.3±9.1 and 32.7±13.1, respectively. The MELD score mean was 23.6±3.67. The main cause of liver dysfunction were chronic hepatitis C virus (n=9). As for renal dysfunction, diabetic nephropathy (n=4) was the most frequent. There were six deaths, two of them by severe dysfunction of the liver graft and four by infectious causes. The 1, 3 and 5 years survival rate in patients undergoing liver-kidney transplantations was 68.8%, 57.3% and 57.3%, respectively.

Conclusion

The survival rates achieved in this series are considered satisfactory and show that this procedure has an acceptable morbidity and survival.     

COMPLICATIONS OF NASOTRACHEAL INTUBATION IN NEONATES, INFANTS AND CHILDREN: A REVIEW OF 4 YEARS' EXPERIENCE IN A CHILDREN'S HOSPITAL

A computerized database was set up to study the incidence andoutcome of complications of nasotracheal intubation in a paediatrichospital. We studied 2953 intensive care admissions over a 4-yrperiod. The overall complication rate was 8%. Accidental extubationand tube blockage were the most frequent events, accountingfor a mean of 3.5% and 2.6% of the complications per year, respectively.Complications were more common in smaller children and therewere differences between fields of intensive care. None of thecomplications was fatal or resulted in serious sequelae. Noneof the children in the study showed clinical symptoms of acquiredsubglottic stenosis before discharge from hospital, and nonehas been readmitted for this condition subsequently.     

PYOGENIC LIVER ABSCESS: A REVIEW OF 10 YEARS’ EXPERIENCE IN MANAGEMENT

Background : Over the past 15 years, diagnostic and interventional radiology techniques have allowed accurate localization of liver abscesses and image-guided percutaneous drainage. This review examines whether these technical advances improve clinical results and discusses the selection of treatment for patients with liver abscesses. Methods : Ninety-eight patients were treated for pyogenic liver abscess (PLA) at the Royal Prince Alfred Hospital, Sydney, between January 1987 and June 1997. The hospital records were examined and clinical presentation, laboratory, radiological and microbiological findings were recorded. Associations between these findings and failure of initial non-operative management were determined using odds ratios with 95% confidence intervals. Independent predictors were then determined by logistic regression. This analysis was repeated to determine factors associated with mortality. Results : Cholelithiasis and previous hepatobiliary surgery were the most frequently identifiable causes of PLA, each responsible in 15 patients. All 98 patients were treated with intravenous antibiotics and in 13 patients this was the only therapy. Of the remaining 85 patients, six proceeded straight to laparotomy and 79 had percutaneous drainage, of whom 15 required subsequent laparotomy. Factors predicting failure of initial non-operative management were unresolving jaundice, renal impairment secondary to clinical deterioration, multiloculation of the abscess, rupture on presentation and biliary communication. The overall hospital mortality rate was 8%. Conclusion : Pyogenic liver abscess remains a disease with significant mortality. Image-guided percutaneous drainage is appropriate treatment for single unilocular PLA. Surgical drainage is more likely to be required in patients who have abscess rupture, incomplete percutaneous drainage or who have uncorrected primary pathology.     

THE ZOLLINGER–ELLISON SYNDROME: A REVIEW OF THE ST VINCENT'S HOSPITAL,MELBOURNE EXPERIENCE

Eight cases of the Zollinger–Ellison syndrome were diagnosed at St Vincent's Hospital in the period 1966–84. Although a rare tumour, its true incidence is almost certainly greater than the number of cases represented in this series. The Zollinger–Ellison syndrome should be suspected in all cases of recurrent peptic ulceration, in cases of peptic oesophagitis not responding to medical treatment, in some cases of diarrhoea and in those cases of peptic ulceration associated with hypercalcaemia. Rarely the gastrinoma may first present as a mass in the head of the pancreas causing obstructive jaundice. Diagnosis has been made easier by estimation of fasting serum gastrins and the use of the secretin test. Localization is difficult. The treatment of the condition remains contentious. In those cases shown to be harbouring a so-called solitary gastrinoma, laparotomy should be performed with a view to resection. If the gastrinoma cannot be localized then it is reasonable to use H2 blocking agents to control hypersecretion. The presence of hypercalcaemia due to hyperparathyroidism must be controlled by parathyroidectomy. Total gastrectomy is reserved for those few cases who for one reason or another are not controlled by adequate H2 blocking therapy. In the presence of malignant gastrinoma with metastatic disease, hypersecretion is controlled by the use of H2 blocking agents. In this group cytotoxic chemotherapy may be used in an attempt to control the mass effects of the tumour.     

PHAEOCHROMOCYTOMA: A REVIEW OF THE ST VINCENT'S HOSPITAL,MELBOURNE EXPERIENCE (1969–84) AND OF RECENT ADVANCES IN MANAGEMENT

Phaeochromocytoma is an unusual tumour which is eminently curable by surgical means. It is difficult to diagnose clinically because it mimics other illnesses. The clinical features of 13 cases of phaeochromocytoma diagnosed at St Vincent's Hospital, Melbourne, between 1969 and 1984 are briefly described. This review emphasizes the several major improvements in both diagnostic and localizing tests which have occurred over the 16 year period of the series. These include the clonidine suppression test and plasma and urine catecholamine estimations in diagnosis and techniques such as CT scanning and the I¹³¹-meta-iodobenzyl-guanidine scan used for localization of the tumour. Careful pre-operative preparation, based on adequate alpha blockade and intra-operative monitoring, is essential for the safe and successful removal of the tumour, which was eventually accomplished for all 12 cases in which removal was attempted. However, the most important step in the diagnosis and treatment of phaeochromocytoma is the initial consideration of the diagnosis. This step depends on the level of awareness of the disorder amongst clinicians.     

THE FATE OF PATIENTS WITH LOCALLY ADVANCED BLADDER CANCER TREATED CONSERVATIVELY WITH NEOADJUVANT CHEMOTHERAPY, EXTENSIVE TRANSURETHRAL RESECTION AND RADIOTHERAPY: 10-YEAR EXPERIENCE

Purpose

We asses the results of bladder preservation for infiltrating cancer. The potential for neoadjuvant chemotherapy followed by extensive transurethral resection and radiotherapy was evaluated in 40 patients with T2-T4a G2-G3 bladder carcinoma.

Materials and Methods

From 1983 to 1995, 40 patients with bladder cancer underwent bladder sparing treatment, consisting of neoadjuvant chemotherapy, extensive transurethral resection and radiotherapy. Most patients had T3G3 cancer. A deep transurethral resection biopsy was performed before and after chemotherapy, and an extensive transurethral resection was repeated at the end of radiotherapy. Of the patients 30 received cisplatin and methotrexate and 10 also received vinblastine. Total dose of radiotherapy was 60 to 65 Gy. Recurrent superficial tumors were treated transurethrally. Radical cystectomy was considered for persistent or recurrent invasive disease.

Results

Complete response occurred in 19 patients (47.5%) after chemotherapy, and in 8 patients after transurethral resection and radiotherapy (67.5%). Within 10 years 8 responding patients (30%) had local recurrences and 3 underwent cystectomy. Of the patients 14 (35%) are alive, including 13 with no evidence of disease (mean survival 65 months), 5 died of unrelated disease and 21 (52.5%) died of distant metastases (mean survival 28 months). Of the 21 patients 14 had residual tumor after radiotherapy, 3 presented with distant metastases after vesical infiltrating recurrence and 4 had distant metastases in the absence of locoregional recurrence. In 22 patients (55%) the bladder was salvaged. Patients with complete response to chemotherapy had a low risk for recurrent infiltrating tumors and metastases.

Conclusions

Complete tumor control was maintained at 5 years in more than 50% of the patients treated conservatively. Bladder salvage is feasible in select patients.     

COMPARISON OF HEPATIC PROFILE IN PRE AND POSTOPERATIVE OF BARIATRIC SURGERY: PRIVATE VS PUBLIC NETWORK

Background:

Obesity is associated to several comorbidities, including nonalcoholic fatty liver disease, which implicates in isolated steatosis to steatohepatitis. The latter may progress to severe manifestations such as liver fibrosis, cirrhosis and hepatocellular carcinoma.

Aim:

To compare the presence of advanced liver fibrosis before and after bariatric surgery in patients of private and public health system.

Methods:

Patients from public and privative networks were studied before and after bariatric surgery. The presence or absence of advanced hepatic fibrosis was evaluated by NAFLD Fibrosis Score, a non-invasive method that uses age, BMI, AST/ALT ratio, albumin, platelet count and the presence or absence of hyperglycemia or diabetes. The characteristics of the two groups were compared. The established statistical significance criterion was p<0.05.

Results:

Were analyzed 40 patients with a mean age of 34.6±9.5 years for private network and 40.6± 10.2 years for public. The study sample, 35% were treated at private health system and 65% in the public ones, 38% male and 62% female. Preoperatively in the private network one (7.1%) patient had advanced liver fibrosis and developed to the absence of liver fibrosis after surgery. In the public eight (30.8%) patients had advanced liver fibrosis preoperatively, and at one year after the proportion fell to six (23%).

Conclusion:

The non-alcoholic fatty liver disease in its advanced form is more prevalent in obese patients treated in the public network than in the treated at the private network and bariatric surgery may be important therapeutic option in both populations.