Epitope load identifies kidney transplant recipients at risk of allosensitization following minimization of immunosuppression

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Laparoscopic repair of a perforated marginal ulcer 2 years after gastric bypass

The authors present the case of a 43-year-old women who underwent a laparoscopic gastric bypass in 2003 for morbid obesity. They report that 2 years later, she had maintained significant weight loss, but had developed acute abdominal pain, followed by nausea and emesis. In the emergency room, she had diffuse tenderness, tachycardia, and leukocytosis. After initial resuscitation, a computed tomography was performed, which showed free air above the liver and thickened small bowel loops. She was brought emergently to the operating room for laparoscopy. At surgery, turbid fluid and inflamed small bowel loops were seen. A perforated marginal ulcer was discovered in the Roux limb, approximately 2 cm distal to the gastrojejunal anastomosis. The perforation was oversewn primarily and patched with omentum. The repair was tested by intraoperative endoscopy. A gastrostomy tube also was placed within the gastric remnant for enteral access. The patient did extremely well postoperatively, and had an uneventful postoperative course. She was discharged on postoperative day 4. The gastrostomy tube was removed at 1 month, and at this writing, she remains well since surgery. An upper endoscopy at 2 months was completely normal, and the Helicobacter pylori test results were negative. The gastric pouch had not significantly enlarged since initial surgery, as indicated by both endoscopy and barium study. Marginal ulcer is reported to be 0.6% to 16% after laparoscopic gastric bypass [1]. Etiologies include gastrogastric fistula, excessively large gastric pouch containing antral mucosa, H. pylori infection, nonsteroidal antiinflammatory use, and smoking [2]. Unfortunately, none of these applied to the reported patient. Because her exact etiology remains unknown, she at this writing continues to receive proton pump inhibitor therapy. Electronic supplementary material The online version of this article (doi: ) contains supplementary material, which is available to authorized users.     

Measuring quality and level of care provided by family caregivers of persons with dementia: protocol for a systematic review of validated instruments

BackgroundChanges in the quality-of-life (QoL) of family caregivers as they care for their loved ones with dementia over time may affect the quality or level of care that these caregivers provide. We do not know if validated instruments exist to directly measure this quality or level of care. The purpose of this systematic review is to identify validated instruments for measuring the quality or level of care provided by family caregivers of persons with dementia.MethodsWe will include articles containing a validated instrument or questionnaire designed to measure quality or level of care provided by the aforementioned group of caregivers. The included articles may utilize the tools in primary or secondary data analyses, or evaluate the tools'' psychometric properties. The following electronic databases will be searched from inception date to the present: Medline, CINAHL Complete, Cochrane Central, and PsycINFO. We will also search the gray literature, the reference lists of included articles, and contact experts in the field to help identify relevant instruments. Included articles will be required to report on an instrument measuring at least one of the following outcomes: quality of care, level of care, appropriateness of care, amount of time spent providing care, and caregiver performance. Two reviewers will independently screen retrieved citations, extract data, and assess the methodological quality of each included article. A narrative synthesis method will be used to describe the findings.DiscussionResults of this systematic review will show whether validated instruments exist to measure the quality or level of care provided by family caregivers of persons living with dementia. This will make it possible to develop initiatives that are targeted towards improving the quality or level of care provided by family caregivers.     

Fibrosis Progression According to Epithelial‐Mesenchymal Transition Profile: A Randomized Trial of Everolimus Versus CsA

Markers of epithelial‐mesenchymal transition (EMT) may identify patients at high risk of graft fibrogenesis who could benefit from early calcineurin inhibitor (CNI) withdrawal. In a randomized, open‐label, 12‐month trial, de novo kidney transplant patients received cyclosporine, enteric‐coated mycophenolate sodium (EC‐MPS) and steroids to month 3. Patients were stratified as EMT+ or EMT? based on month 3 biopsy, then randomized to start everolimus with half‐dose EC‐MPS (720 mg/day) and cyclosporine withdrawal (CNI‐free) or continue cyclosporine with standard EC‐MPS (CNI). The primary endpoint was progression of graft fibrosis (interstitial fibrosis/tubular atrophy [IF/TA] grade increase ≥1 between months 3–12) in EMT+ patients. 194 patients were randomized (96 CNI‐free, 98 CNI); 153 (69 CNI‐free, 84 CNI) were included in histological analyses. Fibrosis progression occurred in 46.2% (12/26) CNI‐free EMT+ patients versus 51.6% (16/31) CNI EMT+ patients (p = 0.68). Biopsy‐proven acute rejection (BPAR, including subclinical events) occurred in 25.0% and 5.1% of CNI‐free and CNI patients, respectively (p < 0.001). In conclusion, early CNI withdrawal with everolimus initiation does not prevent interstitial fibrosis. Using this CNI‐free protocol, in which everolimus exposure was relatively low and administered with half‐dose EC‐MPS, CNI‐free patients were overwhelmingly under‐immunosuppressed and experienced an increased risk of BPAR.

     

Behavioral Outcomes Following Laparoscopic Sleeve Gastrectomy Performed After Failed Laparoscopic Adjustable Gastric Banding

A healthy diet and good eating behaviors are essential components of long-term success in weight maintenance after bariatric surgery. Although rates of revised bariatric surgery have increased, data on subsequent behavioral outcomes are sparse. The aim of our study was to investigate behavioral outcomes following revised laparoscopic sleeve gastrectomy (R-LSG) that was indicated for failed laparoscopic adjustable gastric banding and compare with outcomes following primary laparoscopic sleeve gastrectomy (P-LSG). Twelve patients who underwent R-LSG and 25 patients who underwent P-LSG between 2007 and 2009 in our medical center completed a questionnaire that assessed weight loss, eating behaviors, physical activity, food tolerance, and satisfaction. The average time elapsed since the operation was 18 months for both groups. In the R-LSG group, more patients reported non-normative eating patterns and less healthy food selection than in the P-LSG group. Food tolerance and satisfaction were also lower after R-LSG. Engagement in regular physical activity increased from 0 to 16.7 % in the R-LSG group and from 8 to 33 % in the P-LSG group. After R-LSG, 58 % reported eating at scheduled times, compared with 85 % after P-LSG. Levels of healthy food selection, food tolerance, normative eating patterns, and physical activity were lower in the R-LSG group than in the P-LSG group. This study highlights the need to develop pre- and post-surgery treatment that would promote better behavioral outcomes in the growing number of individuals undergoing repeat bariatric surgery.     

Subtotal parathyroidectomy with thymectomy for autonomous hyperparathyroidism after renal transplantation

BACKGROUND: There is currently no consensus on the operation that should be performed in patients with tertiary hyperparathyroidism (HPT) after renal transplantation. METHODS:: A retrospective analysis of 70 patients with tertiary HPT who underwent subtotal parathyroidectomy with transcervical thymectomy was performed. RESULTS: Mean (s.d.) follow-up was 5.6(5.0) years. Mean (s.d.) glomerular filtration rate (GFR) at follow-up was 42(29) ml/min and was less than 30 ml/min in 26 patients (37 per cent), 30-60 ml/min in 25 (36 per cent) and more than 60 ml/min in 19 (27 per cent). One patient had persistent disease and was cured after reoperation. No patient was hypercalcaemic. Four patients (6 per cent) with a GFR below 30 ml/min had a parathyroid hormone (PTH) level more than four times the normal value without any signs or symptoms of secondary HPT. One patient (1 per cent) was hypocalcaemic and two (3 per cent) were normocalcaemic, with undetectable or below-normal PTH levels while receiving oral vitamin D and calcium medication. CONCLUSION: Systematic subtotal parathyroidectomy associated with thymectomy is effective in treating most renal transplant recipients with tertiary HPT and also minimizes the recurrence of HPT in patients with declining renal function.     

Liver abscess in Crohn's disease: a report of three cases

Liver abscess is a rare complication of Crohn's disease and must be considered part of the differential diagnosis. We present three case reports and a review of the literature. The incidence of liver abscess is higher in patients with Crohn's disease than in the general population. Since Crohn's disease patients who present with a liver abscess generally do not respond to medical management alone, surgical or percutaneous drainage of the abscess is necessary.     

Bouveret's Syndrome as a Rare Complication of Cholecystolithiasis: Report of a Case

Bouveret's syndrome, which is gastric outlet obstruction caused by a gallstone in the duodenum or pylorus, is a very rare complication of gallstone disease. It occurs most commonly in women (65%), with a median age of 68.6 years. This disorder is usually treated by surgery, but it has also been successfully treated by endoscopy, with or without extracorporeal shock wave lithotripsy. The mortality rate has improved to 12% in recent years. Herein we report the case of a 76-year-old woman with Bouveret's syndrome, and review the literature on this unusual entity. Received: January 7, 2002 / Accepted: May 7, 2002 Reprint requests to: E. Shiloni     

Long-Term (over 10 Years) Retrospective Follow-up of Laparoscopic Adjustable Gastric Banding

Background

Laparoscopic adjustable gastric banding (LAGB) placements have progressively decreased in recent years. This is related to poor long-term weight loss outcomes and necessity for revision or removal of these bands. Long-term outcome results following LAGB are limited. The aim of our study was to determine the long-term outcome after LAGB at our institution.

Objectives

The aim of our study was to determine the long-term outcome after LAGB at our institution.

Setting

The setting of this is Academic Center, Israel.

Methods

Patients who underwent LAGB between 1999 and 2004 were reviewed. Patient comorbidities and weight loss parameters were collected preoperatively and at defined postoperative periods. Improvement in weight loss was defined as percent excess weight lost, and improvement in comorbidities was defined based on standardized reporting definitions.

Results

In total, 74 (80%) patients who underwent LAGB met inclusion criteria. The mean age at LAGB placement was 50.5 ± 9.6 years, and the mean body mass index (BMI) was 45.5 ± 4.8 kg/m². Preoperative comorbidities were diabetes mellitus (13.5%), hypertension (32%), hyperlipidemia (12.1%), obstructive sleep apnea (5.4%), joints disease (10.8%), mood disorders (5.4%), and gastro-esophageal reflux disease (GERD) symptoms (8.1%). The mean follow-up was 162.96 ± 13.9 months; 44 patients (59.4%) had their band removed, and 22 (30%) had another bariatric surgery. The follow-up BMI was 35.7 ± 6.9 (p < 0.001), and the % total weight loss was 21.0 ± 0.13. There was no improvement in any of the comorbidities. GERD symptoms worsened at long-term follow-up (p < 0.001). Undergoing another bariatric procedure was associated with a higher weight loss (OR 12.8; CI 95% 1.62–23.9; p = 0.02).

Conclusion

LAGB required removal in the majority of our patients and showed poor resolution of comorbidities with worsening of GERD-related symptoms. Patients who go on to have another bariatric procedure have more durable weight loss outcomes.