Objective: To analyze the potential effects of preoperative age on postoperative weight loss in patients who underwent Roux-en-Y gastric bypass (RYGBP) with long-term follow-up data. Background: The reasons for individual differences in surgically induced weight loss are not completely understood. To date, there are no available studies specifically aimed at analyzing the effects of age on weight loss in patients undergoing the same operation and with long-term followup data. Methods: Retrospective analysis of prospectively collected data for all patients who underwent RYGBP between 2006 and 2010. To evaluate weight loss, we used preoperative and follow-up body mass index (BMI), analyzed by the mixed-effects linear model for repeated measures. To evaluate age effects, patients were classified in quartiles (<=35 years, 36-42 years, 43-51 years, >=52 years). Results: A total of 489 patients entered the study; preoperatively, the younger group showed a significantly higher BMI (mean BMI: 48.2 in patients aged <=35 years, 46.9 in 36-42 years, 45.5 in 43-51 years, 45.7 in >=52 years, P = 0.014) and a higher percentage of super-obesity (41.6% among patients aged <=35 years, 28.1% among 36-42 years, 27.6% among 43-51 years, 28.3% among >= 52 years, P = 0.047). In spite of this, younger patients experienced a significantly greater and prolonged BMI decrease during the entire follow-up period and the BMI trend over time resulted significantly modified according to age quartiles (P = 0.036). Conclusions: This study provides a new prognostic factor in bariatric surgery: patient age. Because advanced age represents a risk factor for complications and mortality, and given that bariatric surgery may not be as effective in older patients compared to younger subjects, we believe that surgical indications in patients older than 50 years should be carefully weighed up.
INTRODUCTIONLeft-sided portal hypertension is a rare clinical condition most often associated with a pancreatic disease. In case of hemorrhage from gastric fundus varices, splenectomy is indicated. Commonly, the operation is carried out by laparotomy, as portal hypertension is considered a relative contraindication to laparoscopic splenectomy (LS). Although some studies have reported the feasibility of the laparoscopic approach in the setting of cirrhosis-related portal hypertension, experience concerning LS in left-sided portal hypertension is lacking.PRESENTATION OF CASEA 39-year-old man was admitted to the Emergency Department for haemorrhagic shock due to acute hemorrhage from gastric fundus varices. Diagnostic work up revealed a chronic pancreatitis-related splenic vein thrombosis causing left-sided portal hypertension with gastric fundus varices and splenic cavernoma. Following splenic artery embolization (SAE), the case was successfully managed by LS.DISCUSSIONThe advantages of laparoscopic over open splenectomy include lower complication rate, quicker recovery and shorter hospital stay. Splenic artery embolization prior to LS has been used to reduce intraoperative blood losses and conversion rate, especially in complex cases of splenomegaly or cirrhosis-related portal hypertension. We report a case of complicated left-sided portal hypertension managed by LS following SAE. In spite of the presence of large varices at the splenic hilum, the operation was performed by laparoscopy without any major intraoperative complication, thanks to the reduced venous pressure achieved by SAE.CONCLUSIONSplenic artery embolization may be a valuable adjunct in case of left-sided portal hypertension requiring splenectomy, allowing a safe dissection of the splenic vessels even by laparoscopy.
Cholecystectomy-related bile duct injuries (BDI) remain a cause of significant morbidity and debate concerning optimal management is ongoing. We reviewed our experience with surgical management of BDI to assess patterns of referral along with postoperative and long-term outcomes. During September 1996-August 2013, 35 patients were operated in our tertiary care center for a Bismuth-Strasberg grade >A BDI after a cholecystectomy performed elsewhere. Injury grade distribution was as follows: D, n = 3; E1, n = 4; E2, n = 15; E3, n = 5; E4, n = 5; E5, n = 3. Four patients (11.4%) had an associated vascular injury (arterial, n = 2; portal, n = 1; both, n = 1). Treatment was direct repair + Kehr drain placement (n = 1), hepaticojejunostomy (n = 28), hepaticojejunostomy + hepatic resection (n = 5), and liver transplantation (n = 1). There was one postoperative death (2.8%) due to hepatic failure after liver resection; severe (Dindo-Clavien grade ≥3b) complications were observed in 12 (34.3%) patients. Sepsis at referral (OR 17.33, p = 0.007) and laparotomy prior to definitive repair (OR 14, p = 0.04) were the factors associated with severe complications. Median follow-up was 81 (range 12-182) months; two patients were lost to follow-up. Treatment failure (defined as need for reoperation or interventional radiology procedure during follow-up) was observed in 7/32 (21.9%) patients. No association between baseline variables and treatment failure was observed. Post-cholecystectomy BDI represent a heterogeneous entity. The whole armamentarium of the hepatobiliary surgeon is required to achieve proper management. Patients referred with sepsis and requiring laparotomy prior to definitive repair are more prone to develop severe complications.
HighlightsLiterature evidences regarding the evolution of Barrett’s esophagus after sleeve gastrectomy is poor and the relation between sleeve gastrectomy and the development of subsequent esophageal cancer isn’t clear yet.Preoperative upper endoscopy should be performed in order to detect gastroesophageal reflux disease, Barrett’s esophagus, before undergoing bariatric surgery. Post operative monitoring of the upper gastrointestinal tract after sleeve gastrectomy is essential.
In agreement with previous literature we confirm the aggressive nature of pancreatic tumors secreting ACTH, despite radical surgery. Conversely, surgical treatment is effective on the resolution of clinical symptoms.
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