Post Roux-en-Y Gastric Bypass Biliary Dilation: Natural Process or Significant Entity?

Background

Changes in the biliary system after gastric bypass are not well defined. Dilation may be normal or due to biliary tract pathology. The purpose of this study is to review patients who underwent imaging of their biliary system both before and after Roux-en-Y gastric bypass in an effort to elucidate the effect this operation has on hepatic duct diameter.

Methods

Patients with imaging both before and at least 3?months after gastric bypass were analyzed. Hepatic duct was measured at the level of the porta hepatis to determine interval changes.

Results

Thirty-three patients had postoperative imaging at least 3?months following gastric bypass. Mean hepatic duct diameter was 5.2?±?2 and 7.1?±?2.6?mm preoperatively and postoperatively, respectively (p?<?0.01). Patients with prior cholecystectomy had hepatic duct diameters of 7.9?±?1.3 and 9.5?±?3.5?mm preoperatively and postoperatively, respectively (p?=?0.3). Patients who had not previously undergone cholecystectomy had hepatic duct diameters of 4.3?±?1.1 and 6.4?±?1.8?mm preoperatively and postoperatively, respectively (p?<?0.01).

Conclusions

Hepatic duct diameter increases after Roux-en-Y gastric bypass. A better understanding of this phenomenon may limit the need for further work-up in patients with incidentally detected biliary dilation.     

Pulmonary histiocytosis X: comparison of radiographic and CT findings

The authors retrospectively evaluated radiographs, computed tomographic (CT) scans, and results of pulmonary function tests (when available) for 17 patients with biopsy-proved pulmonary histiocytosis X. In 11 patients, high-resolution CT was used. In 12 patients, CT demonstrated cystic air spaces, usually less than 10 mm in diameter. In three of these 12, cysts were the only abnormality, but in six others, nodules (usually less than 5 mm in diameter) were also present. Two patients had only nodules and one, only emphysema. CT showed that many lesions that appeared reticular on plain radiographs were actually cysts. CT showed no central or peripheral concentration of lesions, but it did reveal that many small nodules were distributed in the centers of secondary lobules around small airways. CT findings correlated better with the diffusing capacity (rho = -0.71) than did the plain radiographic findings (rho = -0.57). Thus, CT was better than radiography at showing the morphology and distribution of lung abnormalities.     

Pre-operative staging of rectal cancer: MRI or ultrasound?

Optimal management of rectal cancer depends on obtaining accurate and detailed staging information at the time of diagnosis. The majority of this comes from radiological staging investigations such as computed tomography (CT), magnetic resonance imaging (MRI) and endoanal ultrasound (EAUS). Whilst there is little debate on the use of CT to assess distant spread of disease, there is still variation in the use of MRI or EAUS in the local staging of rectal cancer. Both techniques have their roles but MRI is better able to visualise the entire rectum and mesorectum as well as accurately identify the circumferential resection (CRM) margin in relation to the tumour edge. Breach of the CRM is one of the most important predictors of local recurrence and knowledge of its relationship to the tumour determines initial management. MRI has additional advantages in being able to identify other poor prognostic factors such as extramural venous invasion (EMVI) and mucin deposition, which further influence oncological treatment. It also provides the surgeon with accurate information on the relationship of the tumour to surrounding structures and the sphincter complex which is important for surgical planning. This review highlights the important determinants of local staging in rectal cancer and presents the evidence to answer the question as to which is a better imaging modality—MRI or EAUS?     

Bariatric surgery in patients with liver cirrhosis

BackgroundData regarding the management of bariatric patients with cirrhosis are scarce, and there is no strong evidence that supports a specific approach for this group of patients. The aim of this study was to review our experience with cirrhotic patients undergoing bariatric surgery.MethodsA prospectively maintained database was reviewed to assess the outcomes of bariatric surgery for patients with known cirrhosis and for patients with cirrhosis discovered at surgery (unknown cirrhosis).ResultsFrom April 2004 to September 2011, 23 patients (12 with known cirrhosis and 11 with unknown cirrhosis) met inclusion criteria. There were 14 females and 9 males with a mean age of 51.5±8.3 and a mean body mass index of 48.2±8.6 kg/m2. Child-Pugh classes were A (n = 22) and B (n = 1). Patients had a high frequency of diabetes (83%), dyslipidemia (61%), and hypertension (83%). Procedures performed were laparoscopic Roux-en-Y gastric bypass (LRYGB) (n = 14), laparoscopic sleeve gastrectomy (LSG) (n = 8), and laparoscopic adjustable gastric banding (n = 1). Two patients underwent LSG successfully after transjugular intrahepatic portosystemic shunt. Mean length of hospital stay was 4.3±2.7 days. Complications developed in 8 patients. One patient died of unknown cause 9 months after surgery. No patients had liver decompensation after surgery. The patients lost 67.4%±30.9% of their excess weight at 12 months follow-up and 67.7%±24.8% at 37 months follow-up.ConclusionLRYGB and LSG can be performed without prohibitive complication rates in carefully selected patients with cirrhosis. In our experience, bariatric patients with cirrhosis achieved excellent weight loss and improvement in obesity-related co-morbidities.     

Transoral gastric volume reduction for weight management: technique and feasibility in 18 patients

BackgroundEndoluminal suturing to reduce the gastric volume might provide an additional option for the treatment of obesity. Potential advantages of a nonoperative endoluminal intervention include less pain, the ability to perform it as an outpatient procedure, and a high level of patient acceptance. The purpose of the present pilot study was to demonstrate the feasibility and procedural safety of transoral gastric volume reduction (TRIM procedure) using the Restore Suturing System in patients with a body mass index of 30–45 kg/m². Successful completion of the procedure and adverse events were evaluated at academic/university hospitals.MethodsThis was a nonrandomized feasibility study performed at 2 institutions. After institutional review board approval, the patients underwent the TRIM endoluminal gastric plication procedure with the Restore Suturing System (Restore device). Gastric plications were completed to approximate the anterior and posterior gastric walls to achieve restriction of the upper stomach. The number and location of successful plications were recorded, and patients were monitored for complications. The present report described the short-term procedural results (≤24 hours after the procedure) of the studied cohort.ResultsA total of 18 patients were enrolled in the present study. The TRIM procedure was successfully completed in all patients, with placement of 4–8 plications (average 6 per patient). The average procedure time was 125 ± 23 minutes, and no serious or significant procedure-related complications occurred. After the procedure, common patient complaints were nausea, vomiting, and abdominal discomfort. The first 10 patients enrolled were kept overnight according to the study protocol, and the remaining 8 patients were discharged on the day of the procedure.ConclusionEndoluminal suturing using the TRIM procedure and the Restore device was technically feasible, and no serious or significant procedure-related complications were reported. Weight loss, co-morbidity improvement, and durability are under assessment.     

EZH2 expression in gliomas: Correlation with CDKN2A gene deletion/ p16 loss and MIB‐1 proliferation index

Enhancer of zeste homolog 2 (EZH2) mediated down‐regulation of CDKN2A/p16 has been observed in cell lines as well as in a few carcinomas. However, there is no study correlating EZH2 expression with CDKN2A/p16 status in gliomas. Hence, the present study was conducted to evaluate EZH2 expression in astrocytic and oligodendroglial tumors and correlate with CDKN2A/p16 status as well as MIB‐1 labeling index (LI). Gliomas of all grades (n = 118) were studied using immunohistochemistry to assess EZH2, p16 and MIB‐1 LI and fluorescence in situ hybrization to evaluate CDKN2A gene status. EZH2 expression and CDKN2A homozygous deletion (HD) were both significantly more frequent in high‐grade gliomas (HGG). Further, strong EZH2 expression (LI ≥ 25%) was significantly more common in HGGs without CDKN2A HD (48.7%; 19/39) as compared to cases with deletion (15.8%; 3/19). Loss of p16 expression was noted in 100% and 51.3% of CDKN2A deleted and non‐deleted tumors, respectively. Notably, 80% (16/20) of the CDKN2A non‐deleted HGGs with p16 loss had strong EZH2 expression, in contrast to only 15.8% (3/19) in the deleted group. Loss of p16 expression significantly correlated with MIB‐1 LI, irrespective of EZH2 status. Thus, this study shows that EZH2 expression correlates with tumor grade in both astrocytic and oligodendroglial tumors and hence can be used as a diagnostic marker to differentiate between low and HGGs. Further, this is the first report demonstrating an inverse correlation of strong EZH2 expression with CDKN2A HD in HGGs. Loss of p16 protein expression is mostly attributable to CDKN2A HD and correlates significantly with MIB‐1 LI. Notably, our study for the first time suggests a possible epigenetic mechanism of p16 loss in CDKN2A non‐deleted HGGs mediated by strong EZH2 expression. A hypothetical model for control of proliferative activity in low versus HGGs is therefore proposed.