Duodenal switch versus Roux‐en‐Y gastric bypass for morbid obesity: systematic review and meta‐analysis of weight results,diabetes resolution and early complications in single‐centre comparisons

Long‐term weight loss after Roux‐en‐Y gastric bypass (RYGB) in super‐obese patients has not been ideal. Biliopancreatic diversion with duodenal switch (DS) is argued to be better; however, additional side effects are feared. The aim of the present study was to determine differences in results after DS and RYGB in publications from single‐centre comparisons. A systematic review of studies containing DS and RYGB performed at the same centre was performed. Outcome data were weight results, resolution of comorbid conditions, perioperative results and complications. Main outcome was difference in weight loss after DS and RYGB. Secondary outcomes were difference in resolution of comorbidities, perioperative results and complications. The final analysis included 16 studies with in total 874 DS and 1,149 RYGB operations. When comparing weight results at the longest follow‐up of each study, DS yielded 6.2 (95% confidence interval 5.0–7.5) body mass index units additional weight loss compared with RYGB, P < 0.001. Operative time and length of stay were significantly longer after DS, as well as the risk for post‐operative leaks, P < 0.05. DS is more effective than RYGB as a weight‐reducing procedure. However, this comes at the price of more early complications and might also yield slightly higher perioperative mortality.     

SLOW GROWING FLAT‐TYPE PRIMARY MALIGNANT MELANOMA OF THE ESOPHAGUS TREATED WITH CAP‐ASSISTED EMR

We report a rare case of flat‐type primary malignant melanoma of the esophagus treated with endoscopic mucosal resection (EMR). A 64‐year‐old woman was referred for examination of a small pigmented lesion located in the mid esophagus. On endoscopy, the lesion exhibited almost no change in size over the year. Cap‐assisted EMR was performed en bloc. The histopathological findings showed atypical melanocyte proliferation in the basal layer, spindle cells, and epithelioid cell proliferation with nuclear enlargement and a few mitotic figures. Histopathological examination confirmed the diagnosis of primary malignant melanoma. Immunostaining for S‐100 protein and HMB‐45 antibody were positive, and the Ki‐67 index was low. The patient was discharged without additional surgical resection and/or chemotherapy. The patient had no symptoms and no signs of recurrence 20 months after EMR. There has been no report on a slow growing esophageal melanoma. It is difficult to estimate the malignant behavior of this case.     

Totally minimally invasive Ivor‐Lewis esophagectomy with single‐utility incision video‐assisted thoracoscopic surgery for treatment of mid‐lower esophageal cancer

The study aims to evaluate the safety and availability of totally minimally invasive Ivor‐Lewis esophagectomy (MIIE) with single‐utility incision video‐assisted thoracoscopic surgery. Forty‐one patients with mid‐lower thoracic esophageal cancer were prospectively treated with totally MIIE. Two stages of laparoscopic‐thoracoscopic procedures were performed. The first 29 patients were treated with four‐port video‐assisted thoracoscopic surgery (Group 1); the others were treated with single‐utility incision video‐assisted thoracoscopic surgery (Group 2). Short‐term clinicopathological outcomes were examined. All patients had negative tumor margins and were pathologically staged from T1N0M0 to T3N2M0. Among Group 1, there was one conversion to open surgery. The mean duration of surgery was 268.4 ± 37.8 minutes, and mean blood loss was 207.2 ± 74.1 mL without significant differences between groups. The average thoracic or abdominal lymph node yield was 12.6 ± 7.1 or 6 ± 5.8, respectively. The median postoperative hospital stay was 7 days. No mortalities occurred. Minor morbidity complicated by late‐stage gastroparesis occurred in two patients (4.9%) after discharge. Major morbidities, including intestinal obstruction and anastomotic leakage, occurred in three patients (7.3%) after discharge. Among Group 2, the average operative duration was 275.4 ± 31.2 minutes, and the mean blood loss was 220 ± 94.9 mL. One patient developed late‐stage anastomotic leakage. The average thoracic or abdominal lymph node yield was 14.7 ± 8.8 and 6.3 ± 5.7, respectively. No statistically significant differences were identified between Group 1 and Group 2. MIIE with single‐utility incision video‐assisted thoracoscopic surgery is feasible in patients with mid‐lower thoracic esophageal cancer without compromising the extent of surgical resection and perioperative outcomes.     

Effect of bariatric surgery on circulating FGF‐19: A systematic review and meta‐analysis

Fibroblast growth factor‐19 (FGF‐19) is a gut hormone which interacts with metabolism and is depleted in obesity. There is some indication that the hormone undergoes a resurgence following bariatric surgery (BS), an effect which may contribute to the beneficial outcomes of such procedures. This systematic review and meta‐analysis aims to synthesize the available literature on FGF‐19 levels before and after BS. MEDLINE, Scopus and Web of Science databases were searched, and the effect of different surgical procedures and degrees of body mass index (BMI) reduction on FGF‐19 levels was assessed by DerSimonian and Laird random‐effects model in meta‐analysis and dose–response analyses. This meta‐analysis, which included 474 patients from 25 arms undergoing one of five BS procedures, revealed a significant increase in the levels of circulating FGF‐19 following all‐type BS. Vertical sleeve gastrectomy, duodenal‐jejunal bypass liner and Roux‐en‐Y gastric bypass all significantly increased circulating FGF‐19 levels from baseline. However, gastric banding failed to achieve the same, and in fact, biliopancreatic diversion was associated with decreased circulating FGF‐19. Finally, an inverse association between FGF‐19 and the degree of BMI‐reduction post‐operatively was noted. FGF‐19 is increased by BS and may represent a pharmaceutical target in efforts to reproduce the beneficial effects of BS in a medical setting.     

Long‐term effects of a preoperative smoking cessation programme

Introduction: Preoperative smoking intervention programmes reduce post‐operative complications in smokers. Little is known about the long‐term effect upon smoking cessation. Aim: To discover long‐term quit rates and the reasons behind successful cessation. Materials and Methods: 101 one of 120 smokers, randomised to smoking intervention or no intervention before hip and knee surgery, completed questionnaires concerning smoking after 1 year. We selected representative men and women for focus group interviews. Results: Significantly more patients from the intervention group abstained from smoking for 1 year post‐operatively [13 in 60 patients (22%) vs 2 in 60 (3%), P < 0.01]. Sex (male), low nicotine dependency, non‐smoking spouse and preoperative smoking intervention were related to smoking cessation. All patients gave the same reasons for smoking cessation: improved health and saving money. Follow‐up for 5 years showed 17% of the controls and 8% in the intervention group (P = 0.42) had died. Conclusion: The intervention group had a significantly higher quit rate 1 year after a preoperative smoking cessation programme. Please cite this paper as: Villebro NM, Pedersen T, Møller AM and Tønnesen H. Long‐term effects of a preoperative smoking cessation programme. The Clinical Respiratory Journal 2008; 2: 175–182.