Impact of major co-morbidities on mortality and complications after gastric bypass

BACKGROUND: We hypothesized that major co-morbidities affect survival and complications after gastric bypass. METHODS: A total of 1465 patients undergoing laparoscopic and open gastric bypass between 1995 and 2002 were studied. Patients with a body mass index >or= 35 kg/m(2) and major co-morbidities (group 1, n = 1045) were compared with patients with a body mass index >or= 40 kg/m(2) with minor/no co-morbidities (group 2, n = 420). RESULTS: Group 1 patients were older (43 versus 36 years, P < 0.001) and had a greater BMI (53 versus 50 kg/m(2), P < 0.001). Early postoperative complications were greater in group 1 than in group 2 and included leaks (4.1% versus 1.2%, P < 0.0032) and wound infections (3.9% versus 1.4%, P < 0.0133). Procedure-related mortality in the series was 1.7%. Mortality was 10-fold greater in group 1 (2.3% versus 0.2%, P < 0.0032). The incidence of small bowel obstruction, incisional hernia, and pulmonary embolism was similar in the two groups. Excess weight loss was significantly greater in group 2 (68% versus 62%, P < 0.001) at 1 year. Resolution of group 1 co-morbidities was great, including hypertension in 62%, diabetes in 75%, venous stasis disease in 96%, and pseudotumor cerebri in 98%. CONCLUSION: Outcomes analysis of obesity surgery requires risk stratification. The very low mortality rates in published studies are likely explained by surgical treatment of low-risk patients with minor co-morbidities, such as those seen in group 2. However, despite the increased perioperative risk, the group 1 patients (with major co-morbidities) demonstrated dramatic resolution of their co-morbid conditions, justifying the decision to go forward with surgery. The data support a radical change in treatment philosophy in which morbidly obese individuals should be offered bariatric surgery before major co-morbid conditions develop as a strategy to decrease the operative risk.     

胃癌中hMSH2、p53和PCNA表达的相关性及意义

目的:探讨胃癌中hMSH2、p53和PCNA表达的相关性及意义.方法:采用免疫组织化学SP法,检测胃癌、癌旁和胃炎粘膜中hMSH2、p53和PCNA表达情况.结果:1)3种基因产物在胃癌中的阳性率均显著高于非癌组织,其中,p53和PCNA在低分化癌中的阳性率显著高于高分化癌,有淋巴结转移者显著高于无转移者(P＜0.05).2)胃癌中hMSH2/PCNA及p53/PCNA表达均呈正相关(P＜0.05).结论:hMSH2、p53和.PCNA的异常表达及hMSH2与PCNA之间的相互调节可能与胃癌的发生发展密切相关.     

Effects of gastric bypass procedures on bone mineral density,calcium, parathyroid hormone,and vitamin d

Weight loss after gastric bypass procedures has been well studied, but the long-term metabolic sequelae are not known. Data on bone mineral density (BMD), calcium, parathyroid hormone, and vitamin D were collected preoperatively and at yearly intervals after gastric bypass procedures. A total of 230 patients underwent preoperative BMD scans. Fifteen patients were osteopenic preoperatively, and three patients subsequently developed osteopenia postoperatively within the first year. No patient had or developed osteoporosis. At 1 year, total forearm BMD decreased by 0.55% (n = 91; P = .03) and radius BMD had increased overall by 1.85% (n = 23; P = .008); both total hip and lumbar spine BMD decreased by 9.27% (n = 22; P < .001) and 4.53% (n = 31; P < .001), respectively. By the second postoperative year, BMD in the total forearm had decreased an additional 3.62% (n = 14; P<.001), whereas radius BMD remained unchanged. Although total hip and lumbar spine BMD significantly decreased at 1 year, by year 2 both total hip and lumbar spine BMD only slightly decreased and were not significantly different from before the operation. Serum calcium decreased from 9.8 mg/dL to 9.2 during the first year (not significant [NS]) and then to 8.8 (NS) by the second year. Parathyroid hormone increased from 59.7 pg/mL (nl 10-65 pg/mL) preoperatively to 63.1 during year 1 (NS) and continued to increase to 64.7 by year 2 (NS). No difference was noted among levels of 25-hydroxy vitamin D preoperatively (25.2 ng/mL; nl 10-65 ng/mL), at 1 year (34.4), and at 2 years (35.4). Our data indicate that bone loss is highest in the first year after gastric bypass with stabilization, and that, in some cases, there is an increase in bone density after the first year. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (oral presentation).     

How do family practitioners perceive surgery for the morbidly obese?

BACKGROUND: Little is known about the level of knowledge and comfort with bariatric surgery among family practice physicians. METHODS: Surveys were sent to all family practitioners in Connecticut querying the practice type and knowledge of bariatric surgery. The results were analyzed for the prevalence of opinion. RESULTS: Of 620 surveys sent out, 129 (21%) were completed. Of the 129 respondents, 73% were men, aged 31-79 years, and 92% were board certified, with an average of 19 years' experience. The average body mass index of respondents was 26 kg/m2 (range 16-40). Only 4% of respondents had a body mass index >30 kg/m2. Physicians reported a patient obesity rate of 43%. Of the 129 respondents, 88% believed obesity was difficult to control with diet and exercise alone. Only 6% thought obesity was best controlled surgically. Also, 85% of respondents had referred a patient for gastric bypass, although only 57% were comfortable explaining the procedure. The most common reason for refusal to refer was fear of complications and death. Additionally, 55% correctly listed a body mass index of 40 kg/m2 as qualifying for bariatric surgery without comorbidities; 48% identified the mortality rate of surgery as <1%, with 4% of respondents reporting >10%; and 84% were familiar with gastric bypass, 66% with LapBand, 33% with vertical banded gastroplasty, and 5% with duodenal switch. The respondents believed that nausea was the most common side effect, followed by anemia and fatigue. Finally, 53% believed bowel obstruction was common. CONCLUSIONS: The results of our study have shown that misconceptions about bariatric surgery exist in the family practice community despite the increasing frequency of these procedures. Educational programs need to be designed to assist family practitioners in treating and referring obese patients.     

胃壁内迷走胰腺的X线征象

目的提高对胃壁内迷走胰腺的认识。方法回顾性分析4例手术病理证实的胃壁内迷走胰腺的临床和钡餐检查X线表现。结果4例胃壁内迷走胰腺均发生在胃窦部近幽门区大弯侧,钡餐表现为轮廓较光滑的圆形或卵圆形充盈缺损,直径1～4cm,形态、位置固定,不随胃蠕动或触压而改变;临近黏膜可规整或粗乱,其中,典型的"脐样"征1例。结论主要X线征象为位于胃窦部幽门区大弯侧边缘光滑、位置固定、无溃疡的充盈缺损,难与息肉或平滑肌瘤或间质瘤等鉴别。     

重组人生长激素对荷人胃癌裸鼠移植瘤血管内皮生长因子表达的影响

目的研究重组人生长激素（rhGH）对生长激素受体（GHR）不同表达状态裸鼠人胃癌移植瘤生长及血管内皮生长因子（VEGF）表达的影响。方法采用免疫细胞化学染色法筛选出GHR阳性和阴性表达的细胞株各1株，分别接种于24只裸鼠皮下。将两种细胞接种裸鼠均随机分为对照组（0．9％NaCl，0．2ml／d）、低剂量rhGH组（0．5U·kg^-1·d^-1，0．2ml／d）和高剂量rhGH组（2．5U·kg^-1·d^-1，0．2mL／d）3组，每组8只，各组均连续给药14d，观察并记录裸鼠体重和肿瘤体积变化；采用酶联免疫吸附法测定各组裸鼠血清VEGF含量，免疫组织化学方法检测胃癌组织中VEGF蛋白表达，RT-PCR方法检测胃癌组织VEGFmRNA水平变化。结果筛选出GHR阳性表达的人胃癌细胞株SGC-7901和阴性表达的MKN-45。对于GHR^＋SGC-7901接种裸鼠，rhGH给药组皮下移植瘤体积较对照组增大（P〈0．05），且高剂量rhGH组促增长效应最为显著（P〈0．05），3组间体重差异无统计学意义（P〉0．05）；高剂量rhGH组的血清VEGF浓度为（252．94±15．32）ng／L，明显高于对照组的（49．94±5．73）ng／L和低剂量rhGH组的（167．60±9．54）ng／L（P〈0．05）；对照组VEGF表达为中度阳性，rhGH给药组呈强阳性；高剂量rhGH组肿瘤组织中VEGFmRNA相对表达量为0．6470±0．0447，明显高于对照组的0．3230±0．0258和低剂量rhGH组的0．4120±0．0351（P〈0．05）。对于GHR—MKN-45接种裸鼠，rhGH给药组体重明显大于对照组（P〈0．05）；肿瘤体积大小、血清VEGF水平、肿瘤组织VEGF蛋白及mRNA表达，3组间差异均无统计学意义（P〉0．05）。结论rhGH能促进GHR阳性表达的SGC-7901移植瘤生长，并促进VEGF表达增高；对于GHR阴性的MKN-45移植瘤，则没有表现出明显的促肿瘤生长及促VEGF表达效应。GHR存在可能是rhGH影响VEGF分泌的关键靶点。     

Silastic ring vertical gastric bypass: cohort study with 83% rate of 5-year follow-up

BackgroundSilastic ring vertical gastric bypass (SRVGB) with jejunal interposition is our standard operation for morbidly obese patients. We present the results of 5 years of follow-up in a cohort of patients who underwent SRVGB in 2001.MethodsThe records of all 160 consecutive patients who underwent SRVGB from January to December 2001 were reviewed. Of the 160 procedures, 143 were primary open cases, 14 were revisions from restrictive procedures, and 3 were laparoscopic cases. At 5 years, the body mass index and percentage of excess weight loss was available for 133 patients (83%) at office visits (n = 91, 68.4%), by telephone (n = 40, 30.1%), or by e-mail (n = 2, 1.5%).ResultsOf the 160 patients, 121 were women and 39 were men, with a mean age of 33.15 ± 10.0 years, percentage of ideal body weight of 195.7% ± 40.8%, and body mass index of 44.6 ± 9.3 kg/m². The mean hospital stay was 3 ± 1 days. One patient (.6%) died of a pulmonary embolus. Early complications included 3 cases (1.87%) of upper gastrointestinal bleeding and 4 gastric leaks (2.5%): 2 (1.36%) from primary cases and 2 (14.29%) from revisional cases. Late complications included 32 patients (20%) with incisional hernias, 20 (12.5%) with anemia, 14 (8.8%) with dumping, 4 (2.5%) with gastrojejunal stricture, 2 (1.25%) with intestinal obstruction, and 2 (1.25%) requiring silastic ring surgical removal. The 5-year follow-up data were available for 133 patients (83%). The mean body mass index in this group was 27 ± 5 kg/m², with a percentage of excess weight loss of 83% ± 18.3% at 5 years postoperatively.ConclusionThe results of our study have shown that SRVGB is an effective operation for promoting lasting weight loss, with acceptable mortality and complication rates.     

THE LATEST PROGRESS OF GASTRIC CANCER SURGERY IN JAPAN

Mortality rate of gastric cancer in Japan had been the highest in the world. Development of early detection and effective treatment was the most impor-tant social demand. For the early detection, Japan de-veloped “double contrast X-ray”, “endoscopy and en-doscopic biopsy”, and “mass screening system”. The Japanese nationwide registry collected data of 273,142 gastric cancer patients in the last 30 years. By the ef-forts of early detection, proportion of Stage I cancer increased from 22.5% to 58.1% in the registry. Cu-mulative 5 year survival rate of resected cases was improved from 37.5% （1962） to 68.8% （1991）. Im-provement was remarkable for Stage-II; from 47.7% to 70.3%, and for Stage-III, from 26.4% to 45.0%.     

T淋巴瘤侵袭转移诱导因子1与胃癌细胞侵袭移行能力的相关性研究

目的：检测T淋巴瘤侵袭转移诱导因子1（Tiam1）在胃癌细胞株中的表达并分析其与胃癌细胞侵袭、移行能力的关系。方法：采用层黏连蛋白黏附法，从胃癌MKN-45细胞株（Mo）中筛选获得高黏附亚株（Mh）和低黏附亚株（ML）。应用RT-PCR和SABC免疫组化技术分别检测Tiam 1mRNA与蛋白在Mo、ML、Mh细胞中的表达。应用Boyden小室测定Mo、ML、Mh细胞的体外侵袭、移行能力并分析其与Tiam1表达间的关系。结果：胃癌MKN-45细胞高黏附亚株（MH）的体外侵袭、移行能力均较MKN-45细胞（Mo）及其低黏附亚株（Mo为强（P〈0.05），但Mo与ML细胞间无差异（P〉0.05）。Tiam 1mRNA和蛋白在MH细胞中的表达均较其在Mo和ML细胞中的表达为强（P〈0.05），但在Mo与ML细胞中的表达无差异（P〉0.05）。Tiam1蛋白和mRNA表达水平与胃癌细胞体外侵袭、移行能力呈正相关（P〈0.05或P〈0.01）。结论：Tiam1基因表达水平升高有可能促进胃癌细胞侵袭、移行能力的增强。