Higher Mast Cell Accumulation in Human Adipose Tissues Defines Clinically Favorable Obesity Sub-Phenotypes

The identification of human obesity sub-types may improve the clinical management of patients with obesity and uncover previously unrecognized obesity mechanisms. Here, we hypothesized that adipose tissue (AT) mast cells (MC) estimation could be a mark for human obesity sub-phenotyping beyond current clinical-based stratifications, both cross-sectionally and prospectively. We estimated MC accumulation using immunohistochemistry and gene expression in abdominal visceral AT (VAT) and subcutaneous (SAT) in a human cohort of 65 persons with obesity who underwent elective abdominal (mainly bariatric) surgery, and we validated key results in two clinically similar, independent cohorts (n = 33, n = 56). AT-MC were readily detectable by immunostaining for either c-kit or tryptase and by assessing the gene expression of KIT (KIT Proto-Oncogene, Receptor Tyrosine Kinase), TPSB2 (tryptase beta 2), and CMA1 (chymase 1). Participants were characterized as VAT-MC^low if the expression of both CMA1 and TPSB2 was below the median. Higher expressers of MC genes (MC^high) were metabolically healthier (lower fasting glucose and glycated hemoglobin, with higher pancreatic beta cell reserve (HOMA-β), and lower triglycerides and alkaline-phosphatase) than people with low expression (MC^low). Prospectively, higher MC accumulation in VAT or SAT obtained during surgery predicted greater postoperative weight-loss response to bariatric surgery. Jointly, high AT-MC accumulation may be used to clinically define obesity sub-phenotypes, which are associated with a “healthier” cardiometabolic risk profile and a better weight-loss response to bariatric surgery.

Laparoscopic adjustable gastric band removal and outcome of subsequent revisional bariatric procedures: A retrospective review of 214 consecutive patients

BACKGROUND

Laparoscopic adjustable gastric band (LAGB) removal is required in cases of slippage, erosion, infection, intolerance, or failure in weight loss. The aim of the study was to follow up the patients who underwent band removal and analyze the outcome of subsequent revisional bariatric procedures.

PATIENTS AND METHODS

A retrospective review of consecutive patients who underwent LAGB removal during 3.5 years. All patients underwent a phone interview in early 2015. Patients were divided to three groups following band removal: without additional surgery, laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en Y gastric bypass (LRYGB), and Redo LAGB(Re-LAGB). Outcome of different revisional procedures was compared according to causes and symptoms before band removal, patient satisfaction, weight loss, quality of life (QOL) questionnaire, and the bariatric analysis and reporting outcome system II (BAROSII) score.

RESULTS

Overall 214 patients (73.8% females) with mean age of 41.9 years were enrolled in the study. The mean time between LAGB placement and removal was 81.0 months. Mean % estimated weight loss (%EWL) was 29.6 at time of band removal. There was no difference between groups in patient age, gender, BMI before LAGB, and most co-morbidities. Patients with 1-5 outpatient visits preferred additional surgery. Patients suffering from vomiting from 1 to 10 times per week preferred revision as LSG or LRYGB. Patients with lower BAROS score underwent LSG or LRYGB. Most of the patients with band intolerance underwent conversion to another bariatric procedure, while patients with band erosion and infected band preferred Re-LAGB. Most of the patients without band gained weight. There was a significant improvement in %EWL (39.9 vs 29.6), QOL (1.08 vs 0.07), and BAROS(2.82 vs-0.11) in patients who underwent additional bariatric surgery before and after band removal irrespective of surgery type.

CONCLUSIONS

Patient selection for different revisional bariatric procedures after LAGB removal is a main point for surgery success. This results in high patient satisfaction, EWL, and QOL. All options (Re-LAGB, LSG, LRYGB) are feasible and safe.

Laparoscopic resection of duodenal gastrointestinal stromal tumour

Only a few studies have revealed using laparoscopic technique with limited resection of gastrointestinal stromal tumour (GIST) of the duodenum. A 68-year-old man was admitted to the hospital due to upper gastrointestinal (GI) bleeding. Evaluation revealed an ulcerated, bleeding GI tumour in the second part of the duodenum. After control of bleeding during gastroduodenoscopy, he underwent a laparoscopic wedge resection of the area. During 1.5 years of follow-up, the patient is disease free, eats drinks well, and has regained weight. Surgical resection of duodenal GIST with free margins is the main treatment of this tumour. Various surgical treatment options have been reported. Laparoscopic resection of duodenal GIST is an advanced and challenging procedure requiring experience and good surgical technique. The laparoscopic limited resection of duodenal GIST is feasible and safe, reducing postoperative morbidity without compromising oncologic results.

Giant enterolith in ileal diverticulum following ileoplastic bladder augmentation

INTRODUCTION

When adhesions, internal hernias, malignant intra- and retro-peritoneal neoplasms are excluded in patients presenting with new onset constipation and abdominal mass appearance after previous abdominal surgery, other causes must be considered.

PRESENTATION OF CASE

Giant enteroliths formed within ileal diverticula in the site of small bowel anastomosis may extrude and produce a palpable abdominal lump. Recent experience with such a patient is the basis of this report.

DISCUSSION

Ileal diverticula with interior enteroliths may be suspected in patients presenting with an abdominal lump following previous small bowel resection.

CONCLUSION

Open or laparoscopic assisted surgical resection of the involved segment is the treatment of choice.

Abdominal cocoon as a rare cause of small bowel obstruction in an elderly man: report of a case and review of the literature

Abdominal cocoon is a rare cause of intestinal obstruction usually diagnosed incidentally at laparotomy. The cause and pathogenesis of the condition have not been elucidated. It primarily affects adolescent girls living in tropical and subtropical regions. Several earlier cases have been reported in males. We describe an 82-year-old man presenting with small bowel obstruction without history of previous abdominal surgery. He was treated by warfarin following aortic valve replacement. Abdominal cocoon was detected at laparotomy. Excision of membrane and lysis of adhesions led to relief of obstruction. Abdominal cocoon is a rare pathology that may be found in all kinds of populations. It may be a rare form of small bowel obstruction diagnosed during surgery in elderly patients.

Early relaparoscopy for management of suspected postoperative complications

BACKGROUND

Diagnosis of complications after laparoscopic surgery is difficult and sometimes late.

METHODS

We compared the outcome of patients who had early (<48 h) relaparoscopy for suspected postoperative complication to those where relaparoscopy was delayed (>48 h).

RESULTS

During the study period, 7726 patients underwent laparoscopic surgery on our service. Of these, 57 (0.7%) patients had relaparoscopy for suspected complication. The primary operations were elective in 48 patients and emergent in nine. Thirty-seven patients had early, 20 had delayed, secondary operations. The most common indication in the early group was excessive pain (46%) followed by peritoneal signs in 35%. In the delayed group, the most common indication was signs of systemic inflammatory response syndrome in 30% and peritoneal signs in 25%. Relaparoscopy was negative in 16 (28%) patients with no difference between groups. The identified complication was treated laparoscopically in 37(65%) patients, and the rest were converted. The patients in the delayed group had a significantly longer hospital stay (p < 0.003) and had a higher rate of complications (p < 0.05). They also had a higher mortality rate (10% vs. 2.7%), but the difference was not statistically significant.

CONCLUSIONS

A policy of early relaparoscopy in patients with suspected complications enables timely management of identified complications with expedient resolution.

Laparoscopic diagnosis and treatment of postoperative complications

BACKGROUND

There is no unequivocal attitude to a laparoscopy as to the means in the diagnosis and treatment of postoperative surgical complications. Our study sought to determine the role of laparoscopy in the management of suspected postoperative complications.

METHODS

We performed a retrospective review of the patients who underwent laparoscopy for complications of previous surgery over a 6-year period.

RESULTS

Sixty-four patients underwent laparoscopy for complications during the study period including 49 laparoscopies, 14 laparotomies, and 1 endoscopic procedure. The median delay between operations was 2 +/- 4.5 days. In 18 (28.1%) patients, laparoscopy did not find intra-abdominal pathology. The conversion to open surgery was necessary in 9 (14.1%) patients. Seven patients underwent more than 1 relaparoscopy. No cases of misdiagnosis were observed. Morbidity was 12.5%. There was no laparoscopy-related death.

CONCLUSIONS

Laparoscopy is an effective tool for the management of postoperative complications after open and laparoscopic surgery. It avoids diagnostic delay and unnecessary laparotomy.

Laparoscopic adrenalectomy for adrenal malignancy: a preliminary report comparing the short-term outcomes with open adrenalectomy

BACKGROUND

The laparoscopic approach to adrenal malignancy remains a topic of debate.

METHODS

A retrospective analysis of patients who had an open or laparoscopic adrenalectomy for malignancy at a tertiary care center from 1995 to 2005 were included in this study.

RESULTS

Twenty-six cases were identified: 19 women and 7 men with a median age of 48 years (range, 20-81) underwent 12 open (8 adrenocortical carcinoma [ACC] and 4 metastases) and 14 laparoscopic adrenalectomies (5 ACC, 8 metastases, and 1 lymphoma). Conversion to open surgery was required in 1 laparoscopic case (7%). Cases with obvious invasion to adjacent organs were not approached laparoscopically. There was no difference in age, sex, American Society of Anesthesiologists status or diagnosis between the two groups, but patients in the laparoscopic group had a higher body mass index. Two patients required splenectomies for splenic tears in the open group. There was no difference in operative time between the two groups, but estimated blood loss (200 vs. 550 mL; P = 0.01) and hospital stay (2 vs. 7 days; P = 0.005) were less in the laparoscopic group. The size of tumors removed by open surgery was larger than by laparoscopy (8 vs. 4 cm; P = 0.003). No locoregional recurrences are reported so far in the laparoscopic group.

CONCLUSIONS

Laparoscopic adrenalectomy is both feasible and safe for some malignant tumors of the adrenal gland in experienced hands. However, it cannot be applied to all cases. Careful selection, preoperative staging, and respect for oncologic principles are important considerations in choosing laparoscopic surgery for primary and secondary adrenal malignancy. Short-term outcomes are better when the laparoscopic approach is possible. Confirmation and long-term results with further studies are required.

Presentation and management of port disconnection after laparoscopic adjustable gastric banding

AIM

Laparoscopic adjustable gastric banding (LAGB) is a common and effective minimally invasive procedure in the treatment of morbid obesity. Port and connection tube complications are rarely reported. The aim of this study was to find presenting signs and predictors of tube disconnection from the access port that allow prompt diagnosis and appropriate treatment.

PATIENTS AND METHODS

A retrospective chart review was performed on the 29 patients who underwent 31 laparoscopic reconnections of the connecting tube following LAGB during a 10-year period.

RESULTS

Presenting signs were sudden lower-abdominal pain and free food passage following by weight gain and inability for band adjustment. Additional imaging was used to confirm diagnosis in the first three patients. Diagnostic laparoscopy for suspected acute appendicitis found tube disconnection from the port in one patient. Laparoscopic reconnection was successful in all patients. Access port exchange was done in 23 cases. Two patients had recurrent port disconnection. Band exchange was performed after second port reconnection.

CONCLUSION

Sudden onset of flank or abdominal pain, free eating, weight gain, and inability to adjust the band are signs of port disconnection after LAGB. Education and information for medical staff and patients can help in early recognition of this complication and avoid unnecessary investigations.

Incidence of pheochromocytoma in trauma patients during the management of unrelated illness: A retrospective review

BACKGROUND

Over the last two decades the rate of detection of asymptomatic adrenal masses has increased as a result of the widespread use of abdominal imaging modalities. Incidental pheochromocytoma discovered during the management of an unrelated illness is a rare presentation of these tumors. They can occur in patients treated for multiple trauma with no history of prior arterial hypertension.

METHODS

From January 1995 to December 2005 a total of 45 patients underwent adrenalectomy for incidentaloma. Of these, a pheochromocytoma was detected in 13 patients (29%) seen for an unrelated condition, 3 were in trauma patients. Nine men and 4 women with a mean age 44.5 years (range 21-67) underwent adrenalectomy for incidental pheochromocytoma.

RESULTS

Less than half (6 patients, 46%), and one of the trauma patients had a history of arterial hypertension. Preoperative hormonal studies revealed a pheochromocytoma in 11 patients with incidentalomas. One patient had normal preoperative catecholamines levels. Laparoscopic transabdominal adrenalectomy was attempted in 10 patients with one conversion to open surgery in the case of paraganglioma and one for injury to the left renal vein. Three patients underwent open adrenalectomy. Mean surgery time of trauma patients was 167 (range, 130-235) min. Intraoperative instability (systolic pressure >200 mmHg) requiring nitroprusside and/or labetalol, was observed in 7 patients (54%). There was no postoperative morbidity or mortality. Over the last 10 years, 23% of the pheochromocytomas found incidentally were in trauma patients.

CONCLUSION

Incidentally discovered adrenal masses need to be investigated for pheochromocytoma. This holds specially true for trauma patients who may be put in serious jeopardy should they need surgery for their injuries.

Laparoscopic accessory splenectomy using intraoperative gamma probe guidance

In cases of accessory splenic tissue in postsplenectomy patients, it is of utmost importance to localize the accessory spleen prior to surgery. Several studies have shown the feasibility of laparoscopic resection of accessory splenic tissue using preoperative scintigraphy. We present the cases of three postsplenectomy patients with accessory splenic tissue causing relapsing hematologic disease. Accessory spleens were diagnosed and localized preoperatively by positive uptake of heat-damaged Tc99m-labeled red blood cells using scintigraphy. Two patients with relapse of immune thrombocytopenic purpura and one with hemolytic anemia underwent handheld gamma probe-assisted laparoscopic accessory splenectomy. One patient with immune thrombocytopenic purpura recovered his platelet count at 3-year follow-up. The other patient had a relapse of disease within 3 months despite successful removal of the accessory spleen. The patient with hemolytic anemia had postoperative relapse; two accessory spleens were identified on radionuclide investigation. The use of intraoperative nuclear imaging can greatly aid in localization and provide confirmation of complete laparoscopic excision of the nuclear focus. The technique is especially useful in cases of a small accessory spleen, by avoiding a major open procedure and contributing to good postoperative results.

Rectal bleeding and previous anticoagulant treatment in patients with colorectal cancer do not predict outcome

BACKGROUND

The aim of this study was to determine whether the outcome of patients with colorectal cancer who presented with bleeding and a history of anticoagulant treatment was different from those who did not have bleeding or previous anticoagulant treatment.

METHODS

This was a single institution, retrospective study of patients with colorectal cancer with and without a history of rectal bleeding and treatment with anticoagulants, assessed for age, gender, tumor site, stage, recurrence rate, and survival.

RESULTS

A total of 621 consecutive patients (309 men) with a mean age of 70 years (range, 36-94 years) diagnosed with colorectal cancer between 1998 and 2004 were studied. Of these, 149 patients (24%) were referred for symptoms of rectal bleeding and 161 patients (26%) had been previously treated with anticoagulants. A total of 592 patients (95%) underwent curative or palliative surgery; endoscopic polypectomy was performed in 3 cases only and in 26 patients (4%) surgery was not performed due to advanced disease or critical illness. Patients with bleeding and a history of anticoagulant treatment presented commonly with stage I cancer. In addition, tumor stage III was less common in patients with previous anticoagulant treatment irrespective of presenting signs. Disease-free and overall survival rates were similar in all groups, irrespective of bleeding at presentation or anticoagulant treatment.

CONCLUSIONS

Rectal bleeding and anticoagulant treatment do not affect the outcome of newly diagnosed patients with colorectal cancer.

Sister Mary Joseph's nodule as the first presenting sign of primary fallopian tube adenocarcinoma

Umbilical metastasis (Sister Mary Joseph's nodule) is often the first sign of intraabdominal and/or pelvic carcinoma. We describe the fourth case reported in the literature of Sister Mary Joseph's nodule originating from fallopian tube carcinoma. In a 54-year-old woman, Sister Mary Joseph's nodule was unexpectedly detected during umbilical hernia repair. Subsequent laparoscopy revealed a 2-cm friable tumor located at the fimbriated end of right fallopian tube and 1-cm peritoneal implant in the pouch of Douglas. Laparoscopic bilateral adnexectomy and resection of the peritoneal implant were performed. Because frozen section examination revealed fallopian tube carcinoma, the procedure was continued with laparotomy including total abdominal hysterectomy, omentectomy, and pelvic lymph node sampling. Final diagnosis was stage IIIB fallopian tube carcinoma. The patient received postoperative adjuvant chemotherapy with single-agent carboplatin and has remained alive and with no evidence of disease. It is concluded that in cases of Sister Mary Joseph's nodule, laparoscopy can be a useful tool in the search of the primary tumor in the abdomen and/or pelvis. Laparoscopy can provide crucial information with respect to the location, size, and feasibility of optimal surgical resection of the intraabdominal and/or pelvic tumors.