Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus

BACKGROUND AND OBJECTIVE

The Atlanta classification of acute pancreatitis enabled standardised reporting of research and aided communication between clinicians. Deficiencies identified and improved understanding of the disease make a revision necessary.

METHODS

A web-based consultation was undertaken in 2007 to ensure wide participation of pancreatologists. After an initial meeting, the Working Group sent a draft document to 11 national and international pancreatic associations. This working draft was forwarded to all members. Revisions were made in response to comments, and the web-based consultation was repeated three times. The final consensus was reviewed, and only statements based on published evidence were retained.

RESULTS

The revised classification of acute pancreatitis identified two phases of the disease: early and late. Severity is classified as mild, moderate or severe. Mild acute pancreatitis, the most common form, has no organ failure, local or systemic complications and usually resolves in the first week. Moderately severe acute pancreatitis is defined by the presence of transient organ failure, local complications or exacerbation of co-morbid disease. Severe acute pancreatitis is defined by persistent organ failure, that is, organ failure >48 h. Local complications are peripancreatic fluid collections, pancreatic and peripancreatic necrosis (sterile or infected), pseudocyst and walled-off necrosis (sterile or infected). We present a standardised template for reporting CT images.

CONCLUSIONS

This international, web-based consensus provides clear definitions to classify acute pancreatitis using easily identified clinical and radiologic criteria. The wide consultation among pancreatologists to reach this consensus should encourage widespread adoption.

Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation

OBJECTIVE

To develop a new international classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of published evidence, and worldwide consultation.

BACKGROUND

The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric description of occurrences that are merely associated with severity.

METHODS

A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists, and radiologists who are currently active in clinical research on acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global Web-based survey was conducted and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions.

RESULT

The new international classification is based on the actual local and systemic determinants of severity, rather than description of events that are correlated with severity. The local determinant relates to whether there is (peri)pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri)pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity-mild, moderate, severe, and critical.

CONCLUSIONS

This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa. It provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

Laparoscopic segmentectomy of the liver: from segment I to VIII

OBJECTIVE

To evaluate the surgical techniques necessary to complete total laparoscopic segmentectomy (LS) of all liver segments (I-VIII).

BACKGROUND

When compared to open surgery, preservation of functional hepatic volume may be more difficult during laparoscopic hepatectomy. LS is a possible alternative to hemihepatectomy, but laparoscopic surgical techniques to complete anatomically accurate segmentectomy have not yet been well established.

METHODS

Data of a total of 342 consecutive patients who underwent laparoscopic hepatectomy were reviewed. LS was defined as complete removal of the Couinaud's segment, in which the corresponding hepatic veins are exposed on the raw surface. The laparoscopic approach was facilitated by using intraoperative ultrasonography for each segment and by placing intercostal trocars to expose the root of the right hepatic vein for segmentectomy VII and VIII.

RESULTS

LS was completed in 62 patients: 36 segmentectomies (from I-VIII), 16 bisegmentectomies of the right lobe, and 10 subsegmentectomies were performed. Conversion to open surgery was required in 3 patients (IVa, VI, and VII). When 26 LS of the superior/posterior hepatic (sub)segments (I, IVa, VII, and VIII) were compared with the remaining 36 LS, the former group required a longer operation time (240 [132-390] minutes vs 155 [90-360]) minutes, P < 0.01) and showed an increased amount of blood loss (350 [20-1500] mL vs 100 [10-1100] mL, P = 0.02).

CONCLUSIONS

LS is feasible and has become an essential surgical technique that can minimize the loss of functional liver volume without reducing curability, although further technical advancements are needed to enhance the accuracy of the resection, especially for the superior/posterior segments.

Sleeve gastrectomy for morbid obesity

The rising prevalence of morbid obesity and the increased incidence of super-obese patients (BMI >50 kg/m2) seeking surgical treatments has led to the search for surgical techniques that provide adequate EWL with the least possible morbidity. Sleeve gastrectomy (SG) was initially added as a modification to the biliopancreatic diversion (BPD) and then combined with a duodenal switch (DS) in 1988. It was first performed laparoscopically in 1999 as part of a DS and subsequently done alone as a staged procedure in 2000. With the revelation that patients experienced weight loss after SG, interest in using this procedure as a bridge to more definitive surgical treatment has risen. Benefits of SG include the low rate of complications, the avoidance of foreign material, the maintenance of normal gastro-intestinal continuity, the absence of malabsorption and the ability to convert to multiple other operations. Reduction of the ghrelin-producing stomach mass may account for its superiority to other gastric restrictive procedures. SG should be in the armamentarium of all bariatric surgeons. Nonetheless, long-term studies are necessary to see if it is a durable procedure in the treatment of morbid obesity.

Pancreatic fistula rate after pancreatic resection. The importance of definitions

BACKGROUND

Pancreatic fistula (PF) is still regarded as a serious complication both in terms of frequency and sequelae. The incidence varies greatly in different reports because of the different definitions used. The aim of this study was to compare several definitions of PF encountered in the current literature and to demonstrate that the PF rate in the same group of patients treated in a high volume center is dependent upon the definition applied.

METHODS

A Medline search of the last 10 years was performed as regards the definition of PF. A score was assigned to the reproducible definitions based upon two basic parameters: daily output (cm3) and duration of the fistula represented by the number of days between the postoperative day of onset and the duration of the complication. Four definitions were formulated and were then applied to a group of 242 patients that underwent pancreatic head or intermediate resections with pancreatico-jejunal anastomosis in our Pancreatic Unit between November 1996 and December 2000. Statistical analysis was carried out using the Yates correct chi2 test with statistical significance set at p < 0.05.

RESULTS

Among 26 different definitions identified, 14 were found suitable for the applied score. We formulated four final definitions summarizing the current concepts of PF. The incidence of PF ranged between 9.9 and 28.5% according to the different definitions applied with highly statistical differences between them.

CONCLUSIONS

The PF rate after pancreatic resections is strictly dependent upon the definition used. An overall general agreement for an internationally accepted definition is urgently needed to correctly compare different experiences.

Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial

BACKGROUND

Anastomotic failure is still a significant problem that affects the outcome of pancreaticoduodenectomy. There have been many techniques proposed for the reconstruction of pancreatic digestive continuity, but there have been few prospective and randomized studies that compare their efficacy.

METHODS

In the current work, 144 patients who underwent a pancreaticoduodenectomy with soft residual tissue were assigned randomly to receive either a duct-to-mucosa anastomosis (group A) or a 1-layer end-to-side pancreaticojejunostomy (group B).

RESULTS

The 2 treatment groups were found not to have any differences in regards to vital statistics, underlying disease, or operative techniques. The postoperative course was complicated in 54% of the 144 patients, with a comprehensive incidence of abdominal complications in 36% (group A, 35%; group B, 38%; P=not significant). The principal complication was pancreatic fistulas, which occurred in 14% of patients (group A, 13%; group B, 15%; P=not significant). Two patients (2%) required reoperation; the postoperative mortality rate was 1%.

CONCLUSION

The 2 methods that were studied revealed no significant difference the rate of complications.

Prevention of insect-borne disease: an approach using transgenic symbiotic bacteria

Expression of molecules with antiparasitic activity by genetically transformed symbiotic bacteria of disease-transmitting insects may serve as a powerful approach to control certain arthropod-borne diseases. The endosymbiont of the Chagas disease vector, Rhodnius prolixus, has been transformed to express cecropin A, a peptide lethal to the parasite, Trypanosoma cruzi. In insects carrying the transformed bacteria, cecropin A expression results in elimination or reduction in number of T. cruzi. A method has been devised to spread the transgenic bacteria to populations of R. prolixus, in a manner that mimics their natural coprophagous route of symbiont acquisition.

Early assessment of pancreatic infections and overall prognosis in severe acute pancreatitis by procalcitonin (PCT): a prospective international multicenter study

BACKGROUND

Pancreatic infections and sepsis are major complications in severe acute pancreatitis (AP) with significant impact on management and outcome. We investigated the value of Procalcitonin (PCT) for identifying patients at risk to develop pancreatic infections in severe AP.

METHODS

A total of 104 patients with predicted severe AP were enrolled in five European academic surgical centers within 96 hours of symptom onset. PCT was measured prospectively by a semi-automated immunoassay in each center, C-reactive protein (CRP) was routinely assessed. Both parameters were monitored over a maximum of 21 consecutive days and in weekly intervals thereafter.

RESULTS

In contrast to CRP, PCT concentrations were significantly elevated in patients with pancreatic infections and associated multiorgan dysfunction syndrome (MODS) who all required surgery (n = 10) and in nonsurvivors (n = 8) early after onset of symptoms. PCT levels revealed only a moderate increase in patients with pancreatic infections in the absence of MODS (n = 7), all of whom were managed nonoperatively without mortality. A PCT value of > or =3.5 ng/mL on 2 consecutive days was superior to CRP > or =430 mg/L for the assessment of infected necrosis with MODS or nonsurvival as determined by ROC analysis with a sensitivity and specificity of 93% and 88% for PCT and 40% and 100% for CRP, respectively (P < 0.01). The single or combined prediction of the two major complications was already possible on the third and fourth day after onset of symptoms with a sensitivity and specificity of 79% and 93% for PCT > or =3.8 ng/mL compared with 36% and 97% for CRP > or =430 mg/L, respectively (P = 0.002).

CONCLUSION

Monitoring of PCT allows early and reliable assessment of clinically relevant pancreatic infections and overall prognosis in AP. This single test parameter significantly contributes to an improved stratification of patients at risk to develop major complications.

Laparoscopic adrenalectomy

Laparoscopic adrenalectomy (LA) was first described in the literature in 1992, and has become the preferred method for the removal of benign functioning and non-functioning tumors of the adrenal gland <12 cm. The objectives of the present study are to review the experience of LA gained since it was first done in 1992 and to critically evaluate its effectiveness for the surgical management of endocrine hypertension; specifically pheochromocytoma, aldosteronoma and Cushing's syndrome and disease, as opposed to open adrenalectomy. The benefits of minimally invasive techniques for the removal of the adrenal gland include decreased requirements for analgesics, improved patient satisfaction, shorter hospital stay and recovery time when compared to open surgery. LA can be performed safely for bilateral disease and may become the standard of care for malignant tumors. Current limitations are operator-dependent and not a factor of limitations of minimally invasive techniques. A thorough pre-operative work-up is key for differentiating the various cases of hypertension and adequate pre-operative treatment is paramount when indicated.

Single-port-access (SPA) cholecystectomy: a multi-institutional report of the first 297 cases

BACKGROUND

An important aspect of a new surgical technique is whether it can be performed by other surgeons in other institutions. The authors report the first 297 cases in a multi-institutional and multinational review of laparoscopic cholecystectomy performed via a single portal of entry.

METHODS

Data were collected retrospectively for the initial patients undergoing single-port cholecystectomy by 13 surgeons who performed these procedures in their institutions after training by the authors. The review included operative time, blood loss, incision length, length of hospital stay (LOS), necessary additional trocars, and other parameters important to cholecystectomy. A database of all the single-port-access (SPA) surgeries performed by the surgeons included demographic and procedural details, LOS, complications, and initial follow-up data.

RESULTS

To date, 297 single-port cholecystectomies have been performed for a variety of diagnoses, primarily cholelithiasis. The average operative time was 71 min, and the average LOS was 1-2 days. The average blood loss was minimal. The use of additional port sites outside the umbilicus occurred in 34 of the cases. Of the 35 intraoperative cholangiograms performed, 34 were successful. No significant complications occurred except for seromas and minor postoperative wound infections. These results are comparable with those for standard multiport cholecystectomy. In addition, no access site hernias (ASH) occurred.

CONCLUSIONS

The findings demonstrate that SPA surgery is an alternative to multiport laparoscopy with fewer scars and better cosmesis. One factor affecting the rate for adoption of SPA surgery among other surgeons is the reproducibility of this new procedure. Although this study had insufficient data to determine fully the benefits of SPA surgery, the feasibility of this procedure with safe, acceptable results was demonstrated in this initial large series across multinational institutions.

Changes in insulin resistance following bariatric surgery: role of caloric restriction and weight loss

The prevalence of type 2 diabetes mellitus (T2DM) and obesity in the western world is steadily increasing. Bariatric surgery is an effective treatment of T2DM in obese patients. The mechanism by which weight loss surgery improves glucose metabolism and insulin resistance remains controversial. In this review, we propose that two mechanisms participate in the improvement of glucose metabolism and insulin resistance observed following weight loss and bariatric surgery: caloric restriction and weight loss. Nutrients modulate insulin secretion through the entero-insular axis. Fat mass participates in glucose metabolism through the release of adipocytokines. T2DM improves after restrictive and bypass procedures, and combinations of restrictive and bypass procedures in morbidly obese patients. Restrictive procedures decrease caloric and nutrient intake, decreasing the stimulation of the entero-insular axis. Gastric bypass (GBP) operations may also affect the entero-insular axis by diverting nutrients away from the proximal GI tract and delivering incompletely digested nutrients to the distal GI tract. GBP and biliopancreatic diversion combine both restrictive and bypass mechanisms. All procedures lead to weight loss and decrease in the fat mass. Decrease in fat mass significantly affects circulating levels of adipocytokines, which favorably impact insulin resistance. The data reviewed here suggest that all forms of weight loss surgery lead to caloric restriction, weight loss, decrease in fat mass and improvement in T2DM. This suggests that improvements in glucose metabolism and insulin resistance following bariatric surgery result in the short-term from decreased stimulation of the entero-insular axis by decreased caloric intake and in the long-term by decreased fat mass and resulting changes in release of adipocytokines. Observed changes in glucose metabolism and insulin resistance following bariatric surgery do not require the posit of novel regulatory mechanisms.

An iPSC line from human pancreatic ductal adenocarcinoma undergoes early to invasive stages of pancreatic cancer progression

Pancreatic ductal adenocarcinoma (PDAC) carries a dismal prognosis and lacks a human cell model of early disease progression. When human PDAC cells are injected into immunodeficient mice, they generate advanced-stage cancer. We hypothesized that if human PDAC cells were converted to pluripotency and then allowed to differentiate back into pancreatic tissue, they might undergo early stages of cancer. Although most induced pluripotent stem cell (iPSC) lines were not of the expected cancer genotype, one PDAC line, 10-22 cells, when injected into immunodeficient mice, generated pancreatic intraepithelial neoplasia (PanIN) precursors to PDAC that progressed to the invasive stage. The PanIN-like cells secrete or release proteins from many genes that are known to be expressed in human pancreatic cancer progression and that predicted an HNF4α network in intermediate-stage lesions. Thus, rare events allow iPSC technology to provide a live human cell model of early pancreatic cancer and insights into disease progression.

Totally transumbilical laparoscopic cholecystectomy

A recently convened Consortium at the Cleveland Clinic agreed on the term Laparo-Endoscopic Single-Site (LESS) surgery to describe minimally invasive techniques that use a single incision to accomplish laparoscopic procedures. These procedures are done by using either a single port through one fascial incision or multiple ports placed through separate fascial incisions. Because of cost containment issues and the lack of widespread availability of a single port, we currently use multiple reusable ports placed through three separate fascial incisions via a transumbilical incision. As opposed to standard laparoscopic cholecystectomy, a deflecting laparoscope and one articulating instrument are utilized to improve the safety and ease of this procedure. Presented in this video are the steps necessary to perform a LESS cholecystectomy via a transumbilical incision with commercially available instruments.

Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass

BACKGROUND

Marginal ulceration (MU) is a well-known complication after gastrojejunostomy; however, its incidence has rarely been reported in bariatric studies. We present 16 cases of documented MU after laparoscopic gastric bypass (LGBP) that were successfully treated with proton pump inhibition (PPI).

METHODS

All patients undergoing LGBP from October 2002 to August 2005 were entered into a prospective, longitudinal database. All patients who subsequently presented with MU were analyzed. MU was diagnosed when patients presented postoperatively with mid-epigastric pain and/or upper gastrointestinal bleeding that responded to PPI or endoscopic intervention. Analysis of variance and Student's t test were used for the statistical analyses.

RESULTS

MU was diagnosed in 16 (4%) of 347 patients in whom LGBP was performed. An additional 10 patients had symptoms suggestive of MU, which raised the incidence as great as 7%. Of the 26 patients, 18 were women and 8 were men (age range 23-53 years), with a preoperative body mass index 37.1-63.9 kg/m2, similar to that of the patients who did not develop MU. Compared with the patients who did not develop MU, the operative times were longer in the MU group (180.5 versus 140.4 minutes, P <0.001). Of the 26 patients, 10 presented with abdominal pain and 16 with upper gastrointestinal bleeding. The mean interval between the initial LGBP and subsequent MU was 6.3 months (range 1-13). After an initial history and physical examination, upper endoscopy confirmed the diagnosis of MU in 16 patients. Three patients who developed MU were receiving chronic anticoagulation medication. All patients who developed MU began high-dose PPI, which resulted in 100% resolution of MU within 8 weeks. Since January 2005, 73 patients were given prophylactic PPI therapy postoperatively, with no patients subsequently developing MU (P = 0.006).

CONCLUSION

We report 16 documented cases of MU occurring after LGBP. This underreported complication can be successfully treated with PPI, although MU complicated by gastrogastric fistula may require operative intervention. The institution of routine PPI therapy after LGBP lowered the short-term incidence of MU at our institution. Additionally, we recommend that all patients who undergo LGBP be given prophylactic PPI therapy postoperatively.

Laparoscopic pancreatoduodenectomy: a review of 285 published cases

BACKGROUND

Given the difficulty level of minimally invasive pancreatoduodenectomy (MIPD), limited data exist for a comparison to open pancreatoduodenectomies. As the technique becomes more diffuse, issues regarding the adequacy of oncologic margins and lymph node retrieval need to be addressed.

METHODS

All published cases of MIPD were examined. Variables analyzed included conversion rates, operating room time, estimated blood loss, length of stay, follow-up, complications, mortality, lymph node retrieval, and margins.

RESULTS

Twenty-seven articles describing outcomes after MIPD were found, and a total of 285 cases were described. Main malignancy treated was pancreatic adenocarcinoma, accounting for 32% of all cases. Eighty-seven percent were performed totally laparoscopically, and 13% were performed with a hand-assisted approach to facilitate the reconstruction step of the procedure. The rate of conversion to an open procedure was 9%. Estimated blood loss had a weighted average (WA) of 189 mL. Average length of stay had a WA of 12 days, and average follow-up had a WA of 14 months. The overall complication rate was 48%, and the overall mortality rate was 2%. Average lymph nodes retrieved ranged from 7 to 36 nodes, with a WA of 15 nodes, and positive margins of resection were reported to be positive in 0.4% of patients with malignant disease.

CONCLUSIONS

This review found similar outcomes with respect to perioperative morbidity and mortality rates compared to open pancreatoduodenectomies. The oncologic goals of pancreatic resection may be able to be achieved by MIPD, but longer follow-up and larger series are still needed.

Evaluation of resident laparoscopic performance using global operative assessment of laparoscopic skills

BACKGROUND

The Global Operative Assessment of Laparoscopic Skills (GOALS), developed by Vassiliou and colleagues, has construct validity in the assessment of surgical residents' laparoscopic skills in dissection of the gallbladder from the liver bed. We hypothesized that GOALS would have construct validity for the entire laparoscopic cholecystectomy procedure and also for laparoscopic appendectomy.

METHODS

Using GOALS, attending surgeons evaluated PGY1 through PGY5 surgical resident performance during laparoscopic cholecystectomy (LC, n = 51) and laparoscopic appendectomy (LA, n = 43). Scores for five domains (depth perception, bimanual dexterity, efficiency, tissue handling, and autonomy) were recorded on a Web-based operative report generator at the conclusion of all cases. Domain scores were recorded using a 5-point Likert scale. Difficulty of the case was similarly rated on a 5-point scale. For analysis, residents were divided into two groups: novice (PGY1 to 3) and experienced (PGY4 to 5). Biostatistical analysis was performed using a two-sample t-test. Paired t-test was used to compare mean scores of residents who performed both LA and LC.

RESULTS

For both LC and LA, the experienced group scored higher than novices did in all five domains. The differences were significant in all domains. Using the mean of the scores from all 5 domains for both LC and LA, the experienced residents scored significantly better than novices did (LC 3.93 versus 2.76, p < 0.001) (LA 4.22 versus 2.75, p < 0.001). No significant differences were noted in difficulty of the cases (p = 0.060 for LC and p = 0.19 for LA).

CONCLUSIONS

This study provides additional evidence in support of GOALS as an assessment tool for objectively measuring technical skills in laparoscopic surgery.

Transvaginal natural orifice translumenal endoscopic surgery cholecystectomy: early evolution of the technique

INTRODUCTION

Initial excitement for Natural Orifice Transluminal Endoscopic Surgery (NOTES) has been partly tempered by the reality that a NOTES procedure without laparoscopic or needleoscopic-assistance has not been performed by most groups. After safely performing laparoscopically-assisted transvaginal cholecystectomy in an IACUC-approved porcine model, we embarked on an IRB-approved protocol to ultimately perform a pure NOTES cholecystectomy.

MATERIALS AND METHODS

We describe our experience with performing a true NOTES tansvaginal cholecystectomy after safely accomplishing 3 laparoscopically-assisted hybrid NOTES procedures in humans. To overcome the retracting limitations of currently available endoscopes, we used a 5-mm curved or articulating retractor that was placed into the abdomen via a separate colpotomy in the second and third patient. In a fourth patient, pneumoperitoneum to 15 torr was obtained via a transvaginal trocar placed through a colpotomy made under direct vision and endoscopically placed clips were used for both the cystic duct and artery, thus, obviating the need for any transabdominally placed instruments or needles.

RESULTS

This patient was the first patient to undergo a completely NOTES cholecystectomy at our institution and to our knowledge in the United States. She was discharged on the day of surgery and has not suffered any complication after 1 month of follow-up.

CONCLUSION

Pure NOTES transvaginal cholecystectomy without aid of laparoscopic or needleoscopic instruments is feasible and safe in humans. Additional experience with this technique will be required before comparative studies to standard laparoscopy and hybrid techniques are appropriate.

Changes in insulin resistance following bariatric surgery and the adipoinsular axis: role of the adipocytokines, leptin, adiponectin and resistin

The fat mass participates in the regulation of glucose and insulin metabolism through the release of adipocytokines in a mechanism called the adipoinsular axis. Putative adipocytokines include leptin, adiponectin and resistin. Obesity plays an important role in the pathogenesis of insulin resistance and type 2 diabetes mellitus (T2DM). Bariatric surgery for morbidly obese patients leads to rapid and prolonged improvement in insulin resistance and T2DM in the vast majority of patients. We have previously proposed that the rapid improvement in insulin resistance observed following bariatric surgery is mediated by changes in incretin levels of the entero-insular axis and that long-term improvement is modulated by fat mass loss and changes in adipocytokine levels of the adipoinsular axis. In this review, we examine the information that supports a role of leptin, adiponectin and resistin in the development of insulin resistance and T2DM. Increasing levels of leptin and decreasing levels of adiponectin correlate with worsening insulin resistance in obese individuals. We also explore the relationship between changes in adipocytokines following bariatric surgery and long-term improvement in insulin resistance and T2DM. Leptin levels drop and adiponectin levels rise following laparoscopic adjustable gastric banding, gastric bypass and biliopancreatic diversion. These changes correlate with weight loss and improvement in insulin. Although resistin may play an important role in explaining insulin resistance, animal and human studies currently show conflicting results.

Revisional bariatric surgery for inadequate weight loss

When behavioral or anatomic issues are not present, revisional surgery should be approached with a goal of treating malnutrition or enhancing excess weight loss. Unfortunately, no randomized controlled trials currently exist to help the practicing bariatric surgeon choose which revisional procedure to perform. A review of the available literature was undertaken and compared with our standard practices to see if any guidelines could be devised. At our institution, patients who have failed jejunal-ileal bypass are reversed in the setting of malnutrition and converted to a sleeve gastrectomy (SG) followed by duodenal switch (DS) as a second stage procedure in the setting of inadequate weight loss. After failed vertical banded gastroplasty (VBG), patients are converted to a Roux-en-Y gastric bypass (RYGBP). After failed adjustable gastric band (AGB) placement, we perform RYGBP. In the super-obese, we leave the band in place or convert to a DS with band removal. In patients with failed RYGBP, we convert our patients to DS, but placement of an AGB may be an acceptable option.

Laparoscopic sleeve gastrectomy for the super-super-obese (body mass index >60 kg/m(2))

PURPOSE

We reviewed our experience of performing laparoscopic sleeve gastrectomy (LSG) in super-superobese (body mass index >60 kg/m(2)) patients and compared our results with those of laparoscopic adjustable gastric banding (LAGB) performed in similar patients.

METHODS

All LSGs performed by our group were reviewed retrospectively. We analyzed only patients whose preoperative body mass index (BMI) was greater than 60 kg/m(2) and compared the results with a report in the literature of super-super-obese patients treated with LAGB.

RESULTS

Between October 2000 and November 2005 we performed 63 LSGs for super-super-obese patients whose average preoperative BMI was 68 kg/m(2). By 6 months postoperatively, the average BMI had decreased to 58 kg/m(2). Forty-three patients subsequently underwent a second-stage duodenal switch procedure within 1 year. The BMI of the 20 patients who did not undergo further surgery decreased further to 50 kg/m(2), 1 year after the LSG.

CONCLUSIONS

Laparoscopic sleeve gastrectomy is comparable with LAGB for promoting short-term weight-loss in the super-super-obese. The benefits of LSG over LAGB include a decreased need for reoperation; first, because foreign material is not implanted in the body; and second, because the residual ghrelin-producing gastric mass is much smaller.

BRCA1/BRCA2 germline mutations in locally recurrent breast cancer patients after lumpectomy and radiation therapy: implications for breast-conserving management in patients with BRCA1/BRCA2 mutations

PURPOSE

Breast cancer patients treated conservatively with lumpectomy and radiation therapy (LRT) have an estimated lifetime risk of local relapse (ipsilateral breast tumor recurrence [IBTR]) of 10% to 15%. For breast cancer patients carrying BRCA1 or BRCA2 (BRCA1/2) mutations, the outcome of treatment with LRT with respect to IBTR has not been determined. In this study, we estimate the frequency of BRCA1/2 mutations in a study of breast cancer patients with IBTR treated with LRT.

PATIENTS AND METHODS

Between 1973 and 1994, there were 52 breast cancer patients treated with LRT who developed an IBTR within the prior irradiated breast and who were willing to participate in the current study. From our database, we also identified 52 control breast cancer patients treated with LRT without IBTR. The control patients were individually matched to the index cases with respect to multiple clinical and pathologic parameters. Lymphocyte DNA specimens from all 52 locally recurrent patients and 15 of the matched control patients under age 40 were used as templates for polymerase chain reaction amplification and dye-primer sequencing of exons 2 to 24 of BRCA1, exons 2 to 27 of BRCA2, and flanking intron sequences.

RESULTS

After LRT, eight (15%) of 52 breast cancer patients had IBTR with deleterious BRCA1/2 mutations. By age, there were six (40%) of 15 patients with IBTR under age 40 with BRCA1/2 mutations, one (9.0%) of 11 between ages 40 and 49, and one (3.8%) of 26 older than age 49. In comparison to the six (40%) of 15 of patients under age 40 with IBTR found to have BRCA1/2 mutations, only one (6.6%) of 15 matched control patients without IBTR and had a BRCA1/2 mutation (P =.03). The median time to IBTR for patients with BRCA1/2 mutations was 7.8 years compared with 4.7 years for patients without BRCA1/2 mutations (P =.03). By clinical and histologic criteria, these relapses represented second primary tumors developing in the conservatively treated breast. All patients with BRCA1/2 mutations and IBTR underwent successful surgical salvage mastectomy at the time of IBTR and remain alive without evidence of local or systemic progression of disease.

CONCLUSION

In this study, we found an elevated frequency of deleterious BRCA1/2 mutations in breast cancer patients treated with LRT who developed late IBTR. The relatively long time to IBTR, as well as the histologic and clinical criteria, suggests that these recurrent cancers actually represent new primary breast cancers. Early onset breast cancer patients experiencing IBTR have a disproportionately high frequency of deleterious BRCA1/2 mutations. This information may be helpful in guiding management in BRCA1 or BRCA2 patients considering breast-conserving therapy.

Gastric banding: conversion to sleeve, bypass, or DS

A review of conversions of gastric banding for obesity to Roux-en-Y gastric bypass, gastric sleeve, or duodenal switch attempts to determine which revisional procedure best enhances weight loss. Indications for these conversions are multiple and include hardware problems, motility problems, and miscellaneous like inadequate weight loss. Analysis of band conversions to band of 193 patients, and bands to gastric bypass in 214 patients reveals better weight loss with the latter strategy. Smaller cohorts of patients who underwent a biliopancreatic diversion or simply a sleeve gastrectomy are too small to conclude on their efficacy. Prospective randomized trials are needed to determine which revisional procedure is best in the setting of inadequate weight loss of excessive weight regain after gastric adjustable banding for severe obesity.

Review of the clinical, histological, and molecular aspects of pancreatic endocrine neoplasms

Pancreatic endocrine neoplasms (PENs) are rare tumors, and little is known about their genetic and chromosomal alterations. Elucidation of the molecular events involved in PEN carcinogenesis has been hindered by the fact that PENs have been considered a single disease entity. The emergence of novel molecular characterization strategies has, however, made it apparent that these lesions exhibit diverse molecular fingerprints, which will facilitate the precise delineation of PEN prognosis, histopathology, and carcinogenesis.

Effective treatment of stage I uterine papillary serous carcinoma with high dose-rate vaginal apex radiation (192Ir) and chemotherapy

PURPOSE

Uterine papillary serous carcinoma (UPSC) is a morphologically distinct variant of endometrial carcinoma that is associated with a poor prognosis, high recurrence rate, frequent clinical understaging, and poor response to salvage treatment. We retrospectively analyzed local control, actuarial overall survival (OS), actuarial disease-free survival (DFS), salvage rate, and complications for patients with Federation International of Gynecology and Obstetrics (FIGO) (1988) Stage I UPSC.

METHODS AND MATERIALS

This retrospective analysis describes 38 patients with FIGO Stage I UPSC who were treated with the combinations of radiation therapy, chemotherapy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy (TAH/BSO), with or without a surgical staging procedure. Twenty of 38 patients were treated with a combination of low dose-rate (LDR) uterine/vaginal brachytherapy using 226Ra or 137Cs and conventional whole-abdomen radiation therapy (WART) or whole-pelvic radiation therapy (WPRT). Of 20 patients (10%) in this treatment group, 2 received cisplatin chemotherapy. Eighteen patients were treated with high dose-rate (HDR) vaginal apex brachytherapy using 192Ir with an afterloading device and cisplatin, doxorubicin, and cyclophosphamide (CAP) chemotherapy (5 of 18 patients). Only 6 of 20 UPSC patients treated with combination LDR uterine/vaginal brachytherapy and conventional external beam radiotherapy underwent complete surgical staging, consisting of TAH/BSO, pelvic/para-aortic lymph node sampling, omentectomy, and peritoneal fluid analysis, compared to 15 of 18 patients treated with HDR vaginal apex brachytherapy.

RESULTS

The 5-year actuarial OS for patients with complete surgical staging and adjuvant radiation/chemotherapy treatment was 100% vs. 61% for patients without complete staging (p = 0.002). The 5-year actuarial OS for all Stage I UPSC patients treated with postoperative HDR vaginal apex brachytherapy and systemic chemotherapy was 94% (18 patients). The 5-year actuarial OS for Stage I UPSC patients treated with HDR vaginal apex brachytherapy and chemotherapy who underwent complete surgical staging was 100% (15 patients). The 5-year actuarial OS for the 20 Stage I UPSC patients treated with combinations of pre- and postoperative LDR brachytherapy and postop WART was 65%. None of the 6 surgically staged UPSC patients treated with LDR radiation and WART/WPRT developed recurrent disease. For patients with FIGO Stage IA, IB, and IC UPSC who underwent complete surgical staging, the 5-year actuarial DFS by depth of myometrial invasion was 100, 71, and 40%, respectively (p = 0.006). The overall salvage rate for local and distant recurrence was 0%. Complications following HDR vaginal apex brachytherapy included only Radiation Therapy Oncology Group (RTOG) grade 1 and 2 toxicity in 16% of patients. However, complications from patients treated with WART/WPRT, and/or LDR brachytherapy, included RTOG grade 3 and 4 toxicity in 15% of patients.

CONCLUSION

Patients with UPSC should undergo complete surgical staging, and completely surgically staged FIGO Stage I UPSC patients can be effectively and safely treated with HDR vaginal apex brachytherapy and chemotherapy. Both OS and DFS of patients with UPSC are dependent on depth of myometrial invasion. The salvage rate for both local and distant UPSC recurrences is extremely poor. Complications from HDR vaginal apex brachytherapy were minimal.