Bariatric to metabolic surgery: management options and experience at a tertiary centre

Obesity proves to be a growing pandemic with severe health and economic implications. Bariatric surgeries are now recognised as metabolic surgeries given the excellent resolution of metabolic derangements accompanying obesity. This concept of metabolic surgery is now applied to non-obese population with metabolic disorders. The type II diabetes mellitus remission rates as high as 95% have been reported, least with restrictive procedures and maximum with malabsorptive procedures and such effect occurs even before substantial weight loss. This has led to increased understanding of diabetes pathophysiology and formulation of foregut and hindgut hypothesis. The aim of this study was to briefly review the management options for morbid obesity and present the results at a high volume centre. Data from 518 patients who underwent laparoscopic bariatric surgeries at this institute since 2002 were taken up for analysis retrospectively. Study population included 518 patients with 310 males and 208 females. Excess body weight loss and comorbidity resolution rates were analysed. Laparoscopic bariatric surgery is safe and effective for excess body weight loss and confers excellent resolution of associated comorbidities.     

Minimally invasive esophagectomy: thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in prone position--experience of 130 patients

BACKGROUND: To evaluate outcomes after minimally invasive or thoracolaparoscopic esophagectomy (TLE) with thoracoscopic mobilization of the esophagus and mediastinal esophagectomy in prone position. Esophagectomies are being performed increasingly by a minimally invasive route with decreased morbidity and shorter hospital stay compared with conventional esophagectomy. Most series report thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in the left lateral position with respiratory complications up to 8% and prolonged operative time, probably because of inadequate stance of the surgeon during the thoracoscopic part. This study shows the potential of the thoracoscopic part of the procedure in prone position to ease these difficulties. STUDY DESIGN: From January 1997 through April 2005, TLE was performed in 130 patients. All patients had histologically proved squamous cell carcinoma of the middle third of the esophagus. Only one (0.77%) patient received neoadjuvant chemotherapy. The thoracoscopic part of the procedure was performed in prone position with excellent ergonomics, translating into less operative time and better respiratory results. We performed a minilaparotomy to retrieve the specimen owing to bulky tumors. Feeding jejunostomy and pyloromyotomy were performed in all patients. RESULTS: There were 102 men and 28 women. Median age was 67.5 years (range 38 to 78 years). There was no conversion to open method. Median ICU stay was 1 day (range 1 to 32 days) and median hospital stay was 8 days (range 4 to 68 days). Perioperative mortality was 1.54% (n = 2). Anastomotic leak rate was 2.31% (n = 3). There was no incidence of tracheal or lung injury and a very low incidence of postoperative pneumonia. At mean followup of 20 months (range 2 to 70 months), stage-specific survival was similar to open and other minimally invasive series. CONCLUSIONS: TLE with thoracoscopic part in prone position is technically feasible, with a low incidence of respiratory complications and less operative time required. It provides comparable outcomes with other techniques of minimally invasive esophagectomy and most open series. In our experience, we observed a low mortality rate (1.54%), hospital stay of 8 days, and low incidence of postoperative pneumonia. It has the potential to replace conventional and other techniques of minimally invasive esophagectomy.     

Energy-modulating vitamins--a new combinatorial therapy prevents cancer cachexia in rat mammary carcinoma

Mitochondria are the major intracellular organelles producing ATP molecules via the electron transport chain. Cancer cells have a deviant energy metabolism, and a high rate of glycolysis is related to a high degree of dedifferentiation and proliferation. The overall net ATP production is diminished with cancer, which ultimately leads to cancer cachexia. The present study was designed to investigate the altered energy metabolism in cancer cells and to enhance ATP production in the normal host cell metabolism by enhancing the activities of mitochondrial enzymes, using energy-modulating vitamins, and thus prevent cancer cachexia. Female Sprague-Dawley rats were selected for the experimental study. Mammary carcinoma was induced by the oral administration of 7,12-dimethylbenz[a]anthracene (25 mg/kg body weight), and treatment was started by the oral administration of the energy-modulating vitamins riboflavin (45 mg/kg body weight per d), niacin (100 mg/kg body weight per d) and coenzyme Q10 (40 mg/kg body weight per d) for 28 d. Mitochondria were isolated from the mammary gland and liver of all four groups, and the Krebs cycle and oxidative phosphorylation enzymes were assayed. In mammary carcinoma-bearing animals, the activities of the Krebs cycle and oxidative phosphorylation enzymes were significantly decreased. These activities were restored to a greater extent in animals treated with energy-modulating vitamins. From these experimental results, one may hypothesize that the combination therapy of energy-modulating vitamins could be of major therapeutic value in breast cancer.     

Evaluation of antioxidant effect of Semecarpus anacardium Linn. nut extract on the components of immune system in adjuvant arthritis

The effect of Semecarpus anacardium Linn. nut extract (SA) on the level of Lipid peroxides (LPO) and activities of superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), and reduced glutathione (GSH) in the lymphocytes and lymphoid organs, namely spleen and thymus of adjuvant induced arthritic rats, were investigated. The results were compared with normal and untreated arthritic rats. The levels of reactive oxygen species (ROS), namely Hydroxy radical, Superoxide radical, and H2O2 were also measured in spleen, thymus, and lymphocytes of control and experimental animals. Biochemical markers of inflammation namely C-reactive protein (CRP) level and Erythrocyte sedimentation rate (ESR) were determined. Anti-arthritic profile was evaluated from the changes in the paw edema and arthritic scores of arthritic and drug-treated rats. A significant increase in the level of LPO, ROS and decreased levels of antioxidant enzymes in arthritic rats were observed. On treatment with the drug, the above changes were reverted back to near normal levels. The increment in CRP level and ESR observed in arthritic animals were found to be significantly restored in SA treated rats. There were no significant changes in sole drug-administered normal rats. Semecarpus anacardium Linn. nut extract significantly decreased the paw edema and arthritic score in arthritic rats on administration, whereas in untreated arthritic rats, there was a significant edema in the hind paw.     

Management of Neuroblastoma: ICMR Consensus Document

Neuroblastoma (NBL) is the most common extra-cranial solid tumor in childhood. High-risk NBL is considered challenging and has one of the least favourable outcomes amongst pediatric cancers. Primary tumor can arise anywhere along the sympathetic chain. Advanced disease at presentation is common. Diagnosis is established by tumor biopsy and elevated urinary catecholamines. Staging is performed using bone marrow and mIBG scan (FDG-PET/bone scan if mIBG unavailable or non-avid). Age, stage, histopathological grading, MYCN amplification and 11q aberration are important prognostic factors utilized in risk stratification. Low-risk disease including Stage 1 and asymptomatic Stage 2 disease has an excellent prognosis with non-mutilating surgery alone. Perinatal adrenal neuroblastoma may be managed with close observation alone. Intermediate-risk disease consisting largely of unresectable/symptomatic Stage 2/3 disease and infants with Stage 4 disease has good outcome with few cycles of chemotherapy followed by surgical resection. Paraspinal neuroblastomas with cord compression are treated emergently, typically with upfront chemotherapy. Asymptomatic Stage 4S disease may be followed closely without treatment. Organ dysfunction and age below 3 mo would warrant chemotherapy in 4S. High-risk disease includes older children with Stage 4 disease and MYCN amplified tumors. High-risk disease has a suboptimal outcome, though the survival is improving with multimodality therapy including autologous stem cell transplant and immunotherapy. Relapse after multimodality therapy is difficult to salvage. Late presentation, lack of transplant facility, malnutrition and treatment abandonment are additional hurdles for survival in India. The review provides a consensus document on management of NBL for developing countries, including India.     

A case report of venous thrombosis in a leprosy patient treated with corticosteroid and thalidomide

Thalidomide is the drug of choice in the treatment of severe erythema nodosum leprosum (ENL) in men. It has recently been associated with deep venous thrombosis (DVT) when used in treatment of refractory multiple myeloma along with combination chemotherapy. We report a case of DVT in a patient treated for ENL with corticosteroids and thalidomide, and suggest a possible mechanism for the association.     

Tildrakizumab for the treatment of psoriasis

Introduction: Psoriasis is an immune-mediated skin disease amenable to targeted immunotherapy. Tildrakizumab is a humanized IgG1 monoclonal antibody targeting interleukin-23 p19 and is approved for use in moderate to severe psoriasis.

Areas covered: This article reviews the mechanism of action, pharmacokinetics, safety, tolerability, and clinical efficacy of tildrakizumab, administered subcutaneously every 12 weeks, in treatment of moderate to severe psoriasis.

Expert commentary: In two phase 3 clinical trials, tildrakizumab showed a consistent low occurrence of adverse events, underlining safety and tolerance. The long half-life permits subcutaneous injections every 12 weeks. Seventy eight percent of patients achieved PASI 75 (a > 75% improvement from baseline PASI) at 28 weeks, 58% achieved PASI 90, 29% achieved PASI 100 and 70% achieved a Physician’s Global Assessment score of clear or almost clear. A high proportion of patients maintained PASI response after 2 years of treatment. Tildrakizumab improved Dermatology Life Quality Index, psoriasis-related personal relationship problems and sexual difficulties. Baseline PASI score, PGA, and BMI were not predictive of PASI 90 response at week 12, however achievement of PASI 50 by week 8 was predictive of a PASI 90 response at week 12.