Surgery for morbid obesity

The prevalence of morbid obesity in the UK population is rising, bringing with it increased levels of cardiovascular disease, diabetes, arthritis and early mortality. The overall cost to the health service is high, and is set to increase over the coming decades as the overweight population ages. Dietary, lifestyle and pharmacological interventions offer at best reasonable, short-term weight reduction and often fail. Surgical intervention is a safe and effective means of delivering marked long-term weight reduction. This article compares and contrasts the options available for surgical treatment of morbid obesity based on a review of the current literature.     

Progress in the understanding and treatment of chronic anal fissure

BACKGROUND—Chronic anal fissure is a common and painful condition associated with internal anal sphincter hypertonia. Reduction of this hypertonia improves the local blood supply, encouraging fissure healing. Surgical sphincterotomy is very successful at healing these fissures but requires an operation with associated morbidity. Temporary reduction in sphincter tone can be achieved on an outpatient basis by applying a topical nitric oxide donor (for example, glyceryl trinitrate) or injecting botulinum toxin into the anal sphincter.
METHODS—A Medline database was used to perform a literature search for articles relating to the non-surgical treatment of chronic anal fissure.
RESULTS—Review of the literature shows botulinum toxin injection to be more effective at healing chronic anal fissures than topical glyceryl trinitrate. Topical isosorbide dinitrate has not been directly compared with either of these two agents but has a healing rate approaching that of botulinum toxin injection. The main side effect of botulinum toxin injection is temporary faecal incontinence in approximately 2% of cases, whereas topical nitrates cause headaches in 20%-100% of cases. No long term side effects were identified with any of the medical treatments.
CONCLUSION—Chemical sphincterotomy is an effective treatment for chronic anal fissure and has the advantages over surgical treatment of avoiding long term complications (notably incontinence) and not requiring hospitalisation.


     

A large pelvic arteriovenous malformation in an adult patient with cystic fibrosis

We present a prepubertal male cystic fibrosis patient with high circulating oestrogen levels (as a consequence of severe cystic-fibrosis-related hepatobiliary disease) who subsequently developed a large pelvic arteriovenous malformation. This has not previously been described in patients with cystic fibrosis, despite the association between high oestrogen levels and arteriovenous malformations. The aetiology and treatment options of arteriovenous malformations are discussed.


     

外科治疗肥胖症的进展

肥胖症是威胁着现代人健康的重要疾病之一。近年随着人们生活水平的提高,肥胖症发病率明显上升,病态性肥胖患者人数也随之增加。据2014年世界卫生组织(WHO)统计,肥胖症威胁着世界大约13%人的健康,肥胖症已成为全球严重的公共健康问题之一。据2002年中国营养与健康状况调查公布,我国肥胖人数已占总人口的7.1%,10年后这个数字上升为11.9%。近年来,外科技术的发展为肥胖症患者带来新的治疗方式即外科手术治疗,手术治疗是使肥胖症患者获得长期而且稳定减重效果的唯一手段。外科减肥的显著效果已得到国际公认,并且减肥手术减重的同时对代谢性疾病的治疗效果也引起了内外科医师的重视,外科减肥已逐渐成为治疗肥胖症的主要方式。随着微创外科的发展,利用腹腔镜实施减肥手术得到广泛应用,腹腔镜手术现已成为减肥手术的首选途径,目前外科减肥常见术式有腹腔镜Roux-en-Y胃旁路术(laparoscopic Roux-en-Y gastric bypass,LRYGB)、腹腔镜可调节胃束带术(laparoscopic adjustable gastric banding,LAGB)、腹腔镜胆胰转流术(laparoscopic biliopancreatic diversion,LBPD)和腹腔镜袖状胃切除术(laparoscopic sleeve gastrectomy,LSG)四种术式。本文就外科减肥的发展现状作一综述。      

Acne: a review of immunologic and microbiologic factors

Acne vulgaris is a self-limiting skin disorder seen primarily in adolescents, whose aetiology appears to be multifactorial. The four main aetiological factors are hypercornification of the pilosebaceous duct, increased sebum production, colonization with Propionibacterium acnes, and subsequently the production of inflammation. Considerable investigation has addressed the immunologic reaction to extracellular products produced by the acne-causing organism, P acnes. The immunologic response involves both humoral and cell-mediated pathways. Further research should clarify the role of complement, cytotoxins, and neutrophils in this acne-forming response.


     

Simultaneous onset of idiopathic dilated cardiomyopathy in identical middle-aged twins

Idiopathic dilated cardiomyopathy is a primary myocardial disease which is characterised by left ventricular, or biventricular, dilatation and impaired contractility. The precise aetiology is unknown and the relative contribution of genetic and environmental factors is debated. We report two identical male twins of Caucasian origin with idiopathic dilated cardiomyopathy who presented within a few months of each other.


     

Difficulties in provision of bariatric surgical services to the morbidly obese

Morbid obesity (defined as having a body mass index [BMI] > 40 kg/m(2), or BMI > 35 kg/m(2) with obesity-related comorbidities) is a medical disorder associated with increased morbidity and mortality. Management guidelines published by the National Health and Medical Research Council and by similar US and UK bodies have recommended surgery as the most effective treatment available for selected patients with morbid obesity. A recent meta-analysis of obesity surgery has documented its safety and effectiveness in resolving some of the major medical comorbidities that occur in obese patients. To date, no intervention other than surgery has proven either effective or cost-effective in treating severe obesity and its associated medical conditions. Targeting patients with metabolic complications of obesity (eg, type 2 diabetes) could lead to substantial cost savings for the public health system. Currently, Medicare pays for privately insured patients to undergo obesity surgery, while uninsured patients are denied access to surgery in public hospitals. This raises significant equity issues that should be addressed.     

Quadruple therapy for symptomatic spontaneous duodenal ulcer disease

AIM—To investigate Helicobacter pylori eradication in duodenal ulcer patients with a new regimen, lansoprazole 30 mg daily for one or four weeks plus twice daily tetracycline 500 mg, clarithromycin 250 mg, and metronidazole 400 mg.
BACKGROUND—Spontaneous duodenal ulcer is regularly associated with H pylori, and permanent cure follows eradication of this bacterium. Numerous treatments have been proposed and none is ideal, possibly because of primary or acquired antibiotic resistance. Quadruple regimens with proton pump inhibitor therapy and three antibiotics offer promise as the most effective therapy.
METHODS—From November 1995 all patients with spontaneous duodenal ulcer were offered quadruple therapy. A month after completion a carbon 14 urea breath test (UBT) was performed. Sensitivity of H pylori to the antibiotics used was tested in 1992-3, 1996, and 1999.
RESULTS—A total of 331 patients were treated; 313 attended for a UBT, of which 299 were negative (95.5%). Of those patients who had an endoscopy with positive urease test immediately before treatment, 95/101 (94.0%) on lansoprazole for one week and 116/121 (95.8%) on lansoprazole for four weeks had a negative UBT. H pylori antibiotic sensitivity did not change.
CONCLUSION—This regimen produced some of the best results yet seen and may be generally recommended as first line therapy.


     

长程视频脑电图及颅内电极脑电图监测在颞叶癫痫手术中的作用

目的:探讨长程视频脑电图监测及颅内电极脑电图监测在颞叶癫痫手术中的作用。方法:比较44 例颞叶癫痫手术患者术前长程视频脑电图和术中颅内电极脑电图的情况。结果:术后经1~5 年的随访, 36 例(81.8%)患者无癫痫发作(Engel-I 级), 6 例(13.6%) 患者临床发作明显减少(Engel-II 级), 2 例(4.5%) 患者仍有癫痫发作(Engel-III 级), 但程度减轻, 发作时间缩短。40 例(90.9%) 患者的神经心理功能均有不同程度改善。结论:长程视频脑电图监测及术中颅内电极脑电图监测定位准确, 对手术切除颞叶癫痫病灶具有指导意义。     

Non-invasive testing for Helicobacter pylori

Confirmed and potential benefits of eradicating Helicobacter pylori have led to the development of a range of diagnostic tests. As well as techniques using biopsy tissue obtained during endoscopy, a number of non-invasive tests are now available. These may be appropriate for pre-endoscopy screening of younger dyspeptics, for use in research, particularly epidemiological surveys, to confirm successful eradication after treatment, and possibly in the future for screening in asymptomatic populations. Serology requiring laboratory analysis is likely to be the least expensive option, particularly suitable for testing large numbers, while urea breath tests should yield the most accurate results and are appropriate for confirming successful eradication since only current infection is detected. The performance of near-patient tests can lack consistency, but these may be useful for small numbers and where other non-invasive testing is unavailable. Tests should be used with an awareness of their potential limitations in terms of accuracy.


     

Is transcutaneous electrical nerve stimulation an effective analgesia during colonoscopy?

OBJECTIVES—To evaluate the efficacy of transcutaneous electrical nerve stimulation (TENS) as analgesia during colonoscopy.
DESIGN—In a randomised controlled trial, patients undergoing diagnostic colonoscopy were assigned to one of three groups: standard medication only (midazolam); active TENS plus standard medication; or non-functioning TENS and standard medication. Efficacy of TENS was determined using numerical rating scores for pain and the post-procedural evaluation questionnaire.
SETTING—Patients undergoing diagnostic colonoscopy in a teaching hospital.
MAIN OUTCOME—There was no statistically significant differences between the three groups. However in the active TENS group there was a greater variation in "physical discomfort" and "psychological distress", suggesting TENS may be effective in subgroup of patients.


     

Wernicke’s encephalopathy following Roux en Y gastric bypass surgery

Wernicke’s encephalopathy (WE) is a serious neurological disorder characterized by a classical triad of acute mental confusion, ataxia, and opthalmoplegia due to thiamine deficiency. It was initially described in chronic alcoholics; however, any condition resulting in poor nutritional status places the patient at risk of WE. Bariatric surgery is now considered as an emergent cause of WE. The number of bariatric surgery is increasing for morbid obesity. We present a case of a 40-year-old male who presented with confusion and difficulty in maintaining the balance while walking 3 months after Roux en Y gastric bypass surgery. Diagnosis of WE was made on clinical ground and confirmed by magnetic resonance imaging of the brain, which showed bilateral hyperintense signals in paramedian thalami. Parenteral thiamine replacement was started, and patient showed complete recovery.Wernicke’s encephalopathy (WE) is a clinically acquired condition characterized by mental confusion, ataxia, and opthalmoplegia. If WE is left untreated or diagnosed lately, it may lead to a state of chronic mental dysfunction known as Korsakoff’s syndrome in 85% of survivors.1 Literature review identified 104 reported cases of WE after bariatric surgical procedures and in 80 (95%) cases, gastric bypass was the performed procedure.2 Gastric bypass surgery is one of the most commonly performed bariatric surgical procedures. The operation is prescribed to treat morbid obesity defined as a body mass index (BMI) greater than >40 kg/m² with no obesity related comorbidities and BMI > 35 kg/m² with obesity related complications as hypertension, type 2 diabetes mellitus, dyslipidemia, and/or obstructive sleep apnea (who failed conservative treatment).3 Aside from weight loss, these procedures are associated with improvement in obesity related co morbidities as well. However, these procedures are associated with a number of complications, among which neurological complications are not uncommon. We present a case of WE who presented 3 months after Roux en Y gastric bypass. The aim of reporting this case is to increase the awareness on this rare and often underdiagnosed complication of gastric bypass.     

Delivery of surgical care in a district general hospital without high dependency unit facilities

BACKGROUND—Many hospitals lack the facilities for high dependency care, and patients requiring this level of care are nursed on the surgical ward. The aim of this study was to assess the extent of this problem in a district general hospital, looking at the impact of providing high dependency unit (HDU) care at ward level.
METHODS—A 28 bed surgical ward was studied for 39 consecutive days. Patients were assessed as being either appropriately placed (routine) or inappropriately placed (HDU). Nursing interventions and observations over each 24 hour period were recorded for the most dependent patient in each group.
RESULTS—Data were collected for a total of 1092 bed days. Median bed occupancy was 22 patients/day (78%). Inappropriately placed HDU patients accounted for 55 bed days (5%, mean 1.4 patients/day). These patients required more nursing intervention than routine patients.
HDU patients received more observations during a 24 hour period than routine patients (mean 11.3 and 4.2 respectively, p<0.005). The number of observations recorded for a routine patient in a 24 hour period fell when a HDU patient was nursed concurrently on the ward (mean 5.1/24 hours, falling to 3.8 /24 hours in the presence of an HDU patient, p<0.02 ).
CONCLUSIONS—HDU patients require more intensive nursing care than routine surgical patients, and the nursing of HDU patients on the ward adversely affects the quantity of care available for less dependent patients. High dependency care should therefore be provided in dedicated units.
HDU is an essential facility for all surgical patients, including those who require intensive nursing, and the routine surgical patient whose nursing is compromised by the failure to provide comprehensive postoperative care.


     

Enhancing psychosocial adaptation to gastric partitioning for morbid obesity.

Gastric partitioning, a surgical treatment for morbid obesity, challenges patients to drastically change their eating habits and self-image. Preoperative psychiatric assessment should not be aimed simply at selecting patients in whom there are no psychiatric contraindications. Many patients have some degree of risk for postoperative problems. If the risk factors can be identified before surgery, appropriate pre- and postoperative psychologic intervention may help minimize maladaptation.     

Intraoperative glove perforation—single versus double gloving in protection against skin contamination

Surgeons have the highest risk of contact with patients'' blood and body fluids, and breaches in gloving material may expose operating room staff to risk of infections. This prospective randomised study was done to assess the effectiveness of the practice of double gloving compared with single gloving in decreasing finger contamination during surgery.
In 66 consecutive surgical procedures studied, preoperative skin abrasions were detected on the hands of 17.4% of the surgeons. In the double gloving pattern, 32 glove perforations were observed, of which 22 were in the outer glove and 10 in the inner glove. Only four outer glove perforations had matching inner glove perforations, thus indicating that in 82% of cases when the outer glove is perforated the inner glove will protect the surgeon''s hand from contamination. The presence of visible skin contamination was also higher in perforation with the single gloving pattern (42.1%) than with the double gloving pattern (22.7%).
An overwhelming majority of glove perforations (83.3%) went unnoticed. Double gloving was accepted by the majority of surgeons, especially with repeated use. It is recommended that double gloves are used routinely in all surgical procedures in view of the significantly higher protection it provides.


     

Risk factors for acquisition of gentamicin-resistant enterococcal infection: a case-controlled study

High-level gentamicin-resistant enterococci present problems in the treatment of infected patients, especially as synergy between penicillin and gentamicin is lost. Previous studies have suggested various risk factors for the acquisition of these enterococci. A case-controlled study was performed on 17 patients infected with resistant enterococci and 26 infected with sensitive strains who attended a London hospital. The key risk factors for acquisition of infection with high-level gentamicin-resistant enterococci were found to be prior prolonged antibiotic treatment, use of five or more antibiotics, and the presence of a urinary catheter. It is proposed that infection control measures should be targeted at patients at higher risk. In addition, control of antibiotic usage in a hospital may help to prevent acquisition and spread of these organisms.


     

骨髓间充质干细胞移植促进大鼠损伤脊髓的功能恢复

 目的研究骨髓间充质干细胞(MSCs)移植对大鼠脊髓损伤的作用。方法将大鼠MSCs移植到大鼠脊髓损伤处,移植后评估大鼠行为学改变,免疫组织化学染色法观察BrdU标记的MSCs在脊髓损伤处存活情况,辣根过氧化物酶(HRP)逆行示踪,观察脊髓损伤处神经通路的重构建,皮层体感诱发电位(CSEP)测定脊髓损伤处神经通路传导功能的恢复。结果术后移植组评分均高于损伤组,移植组大鼠脊髓损伤区远端检测到BrdU阳性细胞,脊髓损伤近侧端检测到HRP阳性细胞,CSEP波形恢复但波幅减低,潜伏时延长。结论MSCs可在损伤区存活并分化为神经元,在损伤局部形成神经元通路,使损伤脊髓的远端和近端建立联系,神经纤维传导功能部分恢复。     

Anorexia nervosa--diagnosis, aetiology, and treatment.

The aetiology, assessment and treatment of anorexia nervosa are reviewed in the light of the classical accounts of Morton, Lasègue and Gull. The core symptoms are deliberate weight loss, disturbed body image and amenorrhoea, and complications may include cardiac failure, electrolyte disturbances, hypothermia and osteoporosis. Common clinical findings are described. Disturbed brain serotonin activity is implicated in the aetiology of anorexia nervosa, but there is little support for the use of pharmacological treatments. Psychological theories of aetiology are discussed with reference to Bruch, Crisp, Palazzoli and Minuchin: the common theme is the reaction of the patient and her family to the physical and social changes of puberty. Individual and/or family psychotherapy is seen as central to the treatment of anorexia nervosa, and the relevant clinical research is reviewed. The roles of general practitioners, general psychiatrists and eating disorder specialists are discussed in the light of recent consensus treatment guidelines.     

硅胶子宫托保守治疗对盆腔脏器脱垂患者症状和生活质量的影响

 目的探讨硅胶子宫托保守治疗对盆腔脏器脱垂患者症状和生活质量影响的临床疗效。方法对在我院门诊选择硅胶子宫托进行保守治疗的有症状的盆腔脏器脱垂患者进行随访,同时填写生活质量调查问卷(PFDI-20短表)。采用配对资料的秩和检验进行统计分析。结果2005年11月至2009年3月33例ⅢⅣ期有症状的盆腔脏器脱垂患者在我院门诊选择硅胶子宫托进行保守治疗。其中盆底重建手术术后复发2例,子宫切除术后脱垂2例。31例完成随访(10例来院随访,21例电话随访),随访率为93.94%,其中23例(74.19%)持续使用。持续使用子宫托患者随访时间为317个月,平均随访时间为(10.04±2.57)个月。27例(81.82%)完成生活质量调查问卷,包括5例放弃治疗患者。PFDI-20总评分POPDI-6(盆腔脏器脱垂)评分、CARDI-8(肠道脱垂)评分和UDI-6(排尿相关症状)上托前评分分别为(54.16±36.12),(27.78±17.30),(0.61±1.01)和(25.77±24.10)分,上托后分别下降为(20.20±25.98),(4.48±5.88),(0.45±0.84)和(15.28±21.53)分。除CARDI-8评分无明显变化外,其他生活质量量表评分上托前后均具有显著性差异(P<0.05)。结论硅胶子宫托可以明显缓解盆腔脏器脱垂患者脱垂和排尿相关症状,显著改善患者的生活质量。对于盆腔脏器脱垂患者是一种可供选择的、有效的保守治疗方法。     

Tuberculosis of the central nervous system

Tuberculous involvement of the brain and spinal cord are common neurological disorders in developing countries and have recently shown a resurgence in developed ones. Tuberculous meningitis is an important manifestation and is associated with high morbidity and mortality. Diagnosis is based on clinical features, cerebrospinal fluid changes, and imaging characteristics. Bacteriological confirmation is not possible in all cases as serological tests do not have sufficient sensitivity and specificity. The polymerase chain reaction shows promise for the future. Appropriate chemotherapeutic agents should be administered as early as possible, although there is no unanimity concerning chemotherapeutic regimens or optimal duration of treatment. The patient''s clinical stage at presentation is the most important prognostic factor. The role of corticosteroids is controversial but they should be administered to all patients presenting in stage III. Surgical procedures are directed at management of the hydrocephalus. Focal lesions, intracranial tuberculomas, and tuberculous abscesses, are usually located in cerebral or cerebellar hemispheres, uncommonly in brainstem and very rarely in spinal cord. They do not usually require surgical intervention and respond well to antituberculous treatment, along with corticosteroids.