Diet approach before and after bariatric surgery

Bariatric surgery (BS) is today the most effective therapy for inducing long-term weight loss and for reducing comorbidity burden and mortality in patients with severe obesity. On the other hand, BS may be associated to new clinical problems, complications and side effects, in particular in the nutritional domain. Therefore, the nutritional management of the bariatric patients requires specific nutritional skills. In this paper, a brief overview of the nutritional management of the bariatric patients will be provided from pre-operative to post-operative phase. Patients with severe obesity often display micronutrient deficiencies when compared to normal weight controls. Therefore, nutritional status should be checked in every patient and correction of deficiencies attempted before surgery. At present, evidences from randomized and retrospective studies do not support the hypothesis that pre-operative weight loss could improve weight loss after BS surgery, and the insurance-mandated policy of a preoperative weight loss as a pre-requisite for admission to surgery is not supported by medical evidence. On the contrary, some studies suggest that a modest weight loss of 5–10% in the immediate preoperative period could facilitate surgery and reduce the risk of complications. Very low calories diet (VLCD) and very low calories ketogenic diets (VLCKD) are the most frequently used methods for the induction of a pre-operative weight loss today. After surgery, nutritional counselling is recommended in order to facilitate the adaptation of the eating habits to the new gastro-intestinal physiology. Nutritional deficits may arise according to the type of bariatric procedure and they should be prevented, diagnosed and eventually treated. Finally, specific nutritional problems, like dumping syndrome and reactive hypoglycaemia, can occur and should be managed largely by nutritional manipulation. In conclusion, the nutritional management of the bariatric patients requires specific nutritional skills and the intervention of experienced nutritionists and dieticians.

     

Preoperative locoregional re-evaluation by endoscopic ultrasound in pancreatic ductal adenocarcinoma after neoadjuvant chemoradiation

INTRODUCTION: The accuracy of endoscopic ultrasound (EUS) for the diagnosis and staging of pancreatic ductal adenocarcinoma (PDA) has been confirmed. Chemo-radiotherpay (CRT) induces tumor changes which can limit the accuracy of EUS. The aim of our study was to analyze the efficacy of EUS following neoadjuvant CRT comparing findings with the pathology results. PATIENTS AND METHODS: From November 1996 to October 2003, 45 patients with histologically proven and EUS-staged PDA were treated with neo-adjuvant CRT and radical surgery. All were restaged before surgery using both EUS and computed tomography. Fifteen patients were found to have developed distant metastases. Thirty patients finally underwent pancreaticoduodenectomy (N=24) or distal pancreatectomy (N=6). RESULTS: Following CRT, tumor stage was correctly assessed in 12 patients (40%). The most frequent misinterpretation was overestimation of tumor size (N=13, 43.3%). Locoregional vascular invasion of veins was suspected by EUS in 13 patients (43.3%) but surgical findings and the histological examination were both negative. Node status was correctly assessed in 27 patients (90%) but nodal involvement was found on the histological specimen in only 3 patients. CONCLUSION: Preoperative EUS after neoadjuvant CRT for PDA does not enable reliable definitive selection of patients for surgery, probably due to radiation-induced pancreatic changes.     

Arrhythmologic study of 50 patients with arrhythmogenic disease of the right ventricle: prognostic implications

Arrhythmogenic right ventricular disease is a syndrome which involves a wide spectrum of anatomo-clinical features. It is characterised by different levels of right ventricle anomaly, and by life-threatening "right" hyperkinetic ventricular arrhythmias. Fifty consecutive pts were retrospectively examined at the Arrhythmological Centre in Trento between 1977 and 1988. The results of rigorous arrhythmological, echocardiographic and angiographic criteria showed that all pts were affected by arrhythmogenic right ventricular disease. CASE STUDY: 39/50 (78%) males, 11/50 (22%) females; age 30.6 years (11-78) at the time of the first study. METHODS: clinical history in 50/50 pts, electrocardiogram in 50/50 pts, Holter monitoring in 50/50 pts, ergometric test in 49/50 pts, non-invasive analysis using signal-averaging QRS in 17/50 pts, 2D echocardiogram in 50/50 pts, angiography in 38/50 pts, electrophysiological endocavitary study in 35/50 pts. RESULTS: familial 2/50 (4%); 1/50 (2%) was in class II NYHA; first arrhythmia at 24.6 years (8-60); most severe arrhythmia at 27.7 years (9-74). Forty-three out of fifty patients (86%) were symptomatic for arrhythmias: 28/50 (56%) as a result of stress; 20/50 (40%) had life-threatening symptoms; 6/50 (12%) had aborted sudden death. Arrhythmogenic right ventricular disease was "localized" in 42/50 (84%) and "diffused" in 8/50 (16%) and was associated with anomalies of the left ventricle in 30/50 (60%). Electrocardiogram showed: right bundle branch block in 10/50 (20%), negative T wave on the right precordial leads in 19/50 (38%), delayed ventricular potentials in 4/17 (23.5%). Using the electrocardiogram, Holter monitoring and electrophysiological endocavitary study the following were documented: a) clinical ventricular tachycardia in 40/50 (80%): non-sustained ventricular tachycardia in 10/50 (20%), sustained ventricular tachycardia in 30/50 (60%); b) electrically induced ventricular tachycardia in 26/35 (74.2%): non-sustained ventricular tachycardia in 8/35 (22.8%), sustained ventricular tachycardia in 18/35 (51.4%) (clinical sustained ventricular tachycardia in 18/18); c) multiform ventricular tachycardia in 12/50 (24%) (diffused arrhythmogenic right ventricular disease in 3/12 and associated anomalies of the left ventricle in 11/12); d) pleomorphic sustained ventricular tachycardia in 9/30 (30%) (diffused arrhythmogenic right ventricular disease in 2/9, and associated anomalies of the left ventricle in 8/9). Forty-two out of fifty patients (84%) underwent antiarrhythmic treatment. When the study was carried out 6.6 years (1 month-22 years) had passed since the first symptom; follow-up was 2.1 years (1 month-11 years) while the interval between the first symptom and the last check-up was 8.4 years (1-30 years); 2/50 dropped out and 2/50 died suddenly.(ABSTRACT TRUNCATED AT 400 WORDS)     

Vena Cava and Pancreatic head En Bloc Resection for an Invasive Inferior Vena Cava Leiomyosarcoma in a Liver Transplant Patient

BackgroundDe novo neoplasms are one of the major causes of death in patients after the first year of liver transplantation. The occurrence of sarcomas is extremely rare and the survival is often poor. However, early diagnosis and radical surgical treatment, may benefit some select liver transplant patients.MethodWe describe the case of a liver transplant patient who developed a locally advanced inferior vena cava (IVC) leiomyosarcoma, who underwent radical surgical treatment with resection of the IVC associated with duodenopancreatectomy, right nephrectomy, and IVC reconstruction. We address aspects of the diagnosis and surgical strategy.ConclusionThis case report illustrates that IVC and multivisceral resections may be feasible and safe in highly selected liver transplant recipients. Major surgery should not be excluded as treatment option in an immunosuppressed liver transplant patient.     

Room for Improvement: A Systematic Review and Meta-analysis on the Informed Consent Process for Emergency Surgery

ObjectiveTo compare recall of complications and surgical details discussed during informed consent and perception of the consent process in patients undergoing emergent vs elective surgery.MethodsStudies were identified from PubMed, Cochrane, Web of Science, and Scopus from January 1, 1966, through April 18, 2018. Included studies compared patient recall and perception regarding informed consent in those undergoing emergent vs elective surgery. Pooled odds ratios (ORs) were calculated for recall of complications and surgical details, patient satisfaction, perception of sufficient information being delivered on surgical risks, report of having read written consent, and factors that interfered with consent.ResultsEleven observational studies (3178 patients) were included. The rate of recall of surgical complications (255 of 504 [50.6%] vs 321 of 446 [72.0%]; OR, 0.29; 95% CI, 0.11-0.80) was lower in patients undergoing emergent vs elective surgery. Meta-analysis revealed a decreased rate of patient satisfaction with the consent process (319 of 459 [69.5%] vs 882 of 1064 [82.9%]; OR. 0.53; 95% CI, 0.34-0.83) and fewer patients having read the consent form (130 of 395 [32.9%] vs 424 of 714 [59.4%]; OR, 0.35; 95% CI, 0.27-0.46) when undergoing emergent compared with elective surgery. Patients undergoing emergent surgery listed pain, analgesic medications, and fatigue as factors likely to interfere with consent.ConclusionPatients undergoing emergent surgery have poor recall of the informed consent process and surgical complications. Furthermore, patients report lower rates of satisfaction, and with fewer patients reading written consent documentation, our findings illuminate problems with the current communication process. There is a need to develop effective tools to improve informed consent in emergency surgery.     

Hemoperitoneum due to rupture of an omental arterial aneurysm

We report a case of spontaneous hemoperitoneum due to rupture of an omental arterial aneurysm. This source of bleeding is unusual (2 cases published); the diagnosis was made preoperatively by doppler ultrasound and CT scan with IV contrast. Omental resection was performed and histological analysis confirmed the diagnosis. A literature review of the rare cases of hemoperitoneum due to rupture of a digestive arterial aneurysm is done.     

Bisphosphonate-associated osteonecrosis can hide jaw metastases

BACKGROUND: Osteonecrosis of the jaw is a well known potential complication of bisphosphonate treatment but its pathogenesis is poorly understood. The current management of patients with bisphosphonate-associated osteonecrosis (BON) is based on "expert recommendations" and there is a recognized need of better evidence. We report two cases where BON hid jaw metastases and use them to discuss some limitations of the current recommendations. PATIENTS: Two patients undergoing long-term I.V. amino-bisphosphonate treatment for metastatic cancer presented with areas of intraorally exposed jawbone. Bisphosphonate-associated osteonecrosis was diagnosed on the basis of medical history, clinical and radiological features. They underwent surgical resection of the affected jaw due to unrelenting pain and lack of response to conservative treatments. RESULTS: Histological examination of the surgical specimen revealed cancer cells at the margins of the site of osteonecrosis. Our patients did not undergo bone biopsy according to current recommendations, due to lack of clinical and radiological signs suggestive of jaw metastases. CONCLUSIONS: Our findings show that: i) patients with BON may also have jaw metastases; ii) there may not be clinical or imaging hints to this fact and; iii) that a biopsy based on careful selection of the site (with inclusion of necrotic margins) may be needed to reach the correct diagnosis. Further studies should be performed on this topic because of its very important prognostic implications.