Mortality after bariatric surgery: analysis of 13,871 morbidly obese patients from a national registry

OBJECTIVE: To define mortality rates and risk factors of different bariatric procedures and to identify strategies to reduce the surgical risk in patients undergoing bariatric surgery. SUMMARY BACKGROUND DATA: Postoperative mortality is a rare event after bariatric surgery. Therefore, comprehensive data on mortality are lacking in the literature. METHODS: A retrospective analysis of a large prospective database was carried out. The Italian Society of Obesity Surgery runs a National Registry on bariatric surgery where all procedures performed by members of the Society should be included prospectively. This Registry represents at present the largest database on bariatric surgery worldwide. RESULTS: Between January 1996 and January 2006, 13,871 bariatric surgical procedures were included: 6122 adjustable silicone gastric bandings (ASGB), 4215 vertical banded gastroplasties (VBG), 1106 gastric bypasses, 1988 biliopancreatic diversions (BPD), 303 biliointestinal bypasses, and 137 various procedures. Sixty day mortality was 0.25%. The type of surgical procedure significantly influenced (P < 0.001) mortality risk: 0.1% ASGB, 0.15% VBG, 0.54% gastric bypasses, 0.8% BPD. Pulmonary embolism represented the most common cause of death (38.2%) and was significantly higher in the BPD group (0.4% vs. 0.07% VBG and 0.03% ASGB). Other causes of mortality were the following: cardiac failure 17.6%, intestinal leak 17.6%, respiratory failure 11.8%, and 1 case each of acute pancreatitis, cerebral ischemia, bleeding gastric ulcer, intestinal ischemia, and internal hernia. Therefore, 29.4% of patients died as a result of a direct technical complication of the procedure. Additional significant risk factors included open surgery (P < 0.001), prolonged operative time (P < 0.05), preoperative hypertension (P < 0.01) or diabetes (P < 0.05), and case load per Center (P < 0.01). CONCLUSIONS: Mortality after bariatric surgery is a rare event. It is influenced by different risk factors including type of surgery, open surgery, prolonged operative time, comorbidities, and volume of activity. In defining the best bariatric procedure for each patient the different mortality risks should be taken into account. Choice of the procedure, prevention, early diagnosis, and therapy for cardiovascular complications may reduce postoperative mortality.     

Implementation of transanal endoscopic microsurgery (TEM) in Italy: a multicentre investigation

Transanal endoscopic microsurgery (TEM), which was first introduced several years ago, allows the excision of rectal tumours not susceptible to a more traditional endoscopic approach or as an alternative to highly invasive or debilitating procedures. We surveyed the effective implementation of TEM in Italy, the indications adopted by each surgical department and the technical results achieved. We contacted 34 surgical departments and analysed the answers given by 17 centres (those actually using the technique = 50%). Most of these are situated in Northern Italy. A total of 1208 procedures were declared (84% of them performed in 6 centres). The most frequent declared indications were adenomas and T1 and T2 carcinomas (741 cases). The contraindications have to do with the staging, localisation and size of the neoplasms. The mean operative time reported by most of the centres ranged from 60 to 90 minutes. The most frequent complication in 13 departments was haemorrhage. The conclusions reported by some of the surgeons contacted are useful. The implementation of TEM is confined to only a few centres with a large number of treated cases. Overall analysis of the data raised many questions needing to be answered, especially with regard to the proper use of a surgical technique that is difficult but not impossible to implement.     

Motor cortex stimulation for ALS: A double blind placebo-controlled study

Preliminary data suggest that repetitive transcranial magnetic stimulation (rTMS) of the brain may produce a modest slowing of disease progression in amyotrophic lateral sclerosis (ALS). The present study was designed to test the hypothesis that rTMS given as continuous theta burst stimulation (cTBS), repeated monthly for one year, would affect ALS progression. We performed a double blind, placebo-controlled trial. Twenty patients with ALS were randomly allocated to blinded real or placebo stimulation. cTBS of the motor cortex was performed for five consecutive days every month for one year. Primary outcome was the rate of decline as evaluated with the revised ALS functional rating scale (ALSFRS-R). Treatment was well tolerated. There was no significant difference in the ALSFRS-R score deterioration between patients treated with real or placebo stimulation. ALSFRS-R mean scores declined from 32.0 (SD 7.1) at study entry to 23.1 (SD 6.3) at 12 months in patients receiving real cTBS and from 31.3 (SD 6.9) to 21.2 (SD 6.0) in those receiving placebo stimulation. Although cTBS proved a safe procedure, on the basis of the present findings a larger randomized confirmatory trial seems unjustified in ALS patients, at least in advanced stage of the disease.     

A new CYP21A1P/CYP21A2 chimeric gene identified in an Italian woman suffering from classical congenital adrenal hyperplasia form

Background  

More than 90% of Congenital Adrenal Hyperplasia (CAH) cases are associated with mutations in the 21-hydroxylase gene (CYP21A2) in the HLA class III area on the short arm of chromosome 6p21.3. In this region, a 30 kb deletion produces a non functional chimeric gene with its 5' and 3' ends corresponding to CYP21A1P pseudogene and CYP21A2, respectively. To date, five different CYP21A1P/CYP21A2 chimeric genes have been found and characterized in recent studies. In this paper, we describe a new CYP21A1P/CYP21A2 chimera (CH-6) found in an Italian CAH patient.     

Health-related quality of life in epilepsy: findings obtained with a new Italian instrument

The aim of the present study was to evaluate the Epi-QoL, a new Italian-specific measure of health-related quality of life (HRQOL) for adults with epilepsy; the clinical variables that affected the HRQOL score were also assessed. The Epi-QoL is a 46-item self-administered questionnaire focusing on six domains: Physical Functioning, Cognitive Functioning, Emotional Well-Being, Social Functioning, Seizure Worry, and Medication Effects. Eight hundred fifteen patients recruited from 24 secondary and tertiary Italian centers for the care of epilepsy were assessed. The results supported the reliability and validity of the Epi-QoL as a measure of HRQOL. The variables that significantly affected HRQOL scores were: geographic area, gender, seizure frequency, prognostic categories, number of medications, comorbidity, presence of cognitive impairment, psychiatric disturbances, and disability. We believe that a new specific questionnaire for the evaluation of HRQOL in Italy can contribute much to the understanding of the influence of epilepsy on patients' lives.     

Gastric volvulus after laparoscopic left adrenalectomy: case report

In this era of modern technologies, laparoscopic adrenalectomy is a gold standard surgical treatment for benign adrenal lesions. However, being aware of its difficulties and their managements is a very important issue for the surgeons who are interested in minimal invasive surgery. In this article, we are presenting a case of a 57-year-old woman who has undergone laparoscopic left adrenalectomy and in the third postoperative month, had an acute gastric volvulus requiring surgical open treatment. To the best of our knowledge, this report is the first article about a gastric volvulus case after left laparoscopic adrenalectomy.     

Preservative surgery of the kidney for haemorrhagic angiomyolipoma: a report of two cases

Renal angiomyolipomas are very rare benign tumours (3% of renal tumours) that may present as isolated tumours or tumours associated with other pathologies, particularly tuberous sclerosis (40%), neurofibro-matosis, or Sturge-Webers disease. Clinically, renal angiomyolipoma is asymptomatic until the tumour becomes larger than 4 cm, causing urinary symptoms such as pain, infection, and microhaematuria. Rarely, in cases of large hypervascularised lesions, the clinical picture at onset may consist in spontaneous haemorrhage due to vessel rupture. The therapy consists in non-operative treatments for small tumours (< 4 cm) and surgical treatment, probably preservative, for larger tumours. In complicated haemorrhagic cases, an angiographic approach or surgical treatments, possibly conservative, are possible, offering the opportunity for further elective treatment. On the basis of case reports starting with haemorrhage and treated in urgency and of a review of the literature, we conclude that it is possible and mandatory to perform emergency preservative treatments of the kidney with an angiographic or surgical approach, and to ensure haemostasis. Treatment of the disease can be postponed when clinical and environmental conditions are better. Furthermore, we stress the need, once the clinical urgency/emergency is over, to submit the patient to suitable examinations to detect possible associated pathologies (tuberous sclerosis, neurofibromatosis, Sturge-Webers disease) in other parts of the body.