Learning Curve for Laparoscopic Sleeve Gastrectomy: a Cumulative Summation (CUSUM) Analysis

PURPOSE

Bariatric surgery is currently considered the most effective and durable treatment option for morbid obesity. Laparoscopic sleeve gastrectomy (LSG) has become a popular technique and may currently be the most frequently practiced surgical operation to treat obesity. However, no objective analyses of its learning curve have been reported.

OBJECTIVE

to analyze the learning curve for LSG.

MATERIALS AND METHODS

We included all LSGs performed in our hospital (University Hospital, Spain; Public Practice) from April 2013 to February 2016. The learning curve for LSG was evaluated using cumulative sum (CUSUM) analysis. All variables among the learning curve phases were compared.

RESULTS

According to the CUSUM analysis, the learning curve was divided into three unique phases: early learning (the initial 26 patients), acquisition of skills (the middle 30 patients), and mastery of technique (the final 56 patients). The operative time and gastric stenosis significantly decreased with progression of the learning curve without differences in the 30-day postoperative complication rate, postoperative stay, or weight loss.

CONCLUSION

According to this study, the learning curve for LSG can be divided into 3 distinct phases, and about 25 patients are needed to demonstrate an improvement in surgical skill.

Ophthalmological findings in patients with leukaemia in a Colombian population

OBJECTIVE

To report the ocular manifestations in patients with leukaemia.

METHODS

This is a retrospective, descriptive and observational study in patients with ocular manifestations of leukaemia.

RESULTS

A total of 14 eyes were evaluated corresponding to 8 patients (5 women and 3 men) with ocular manifestations of leukaemia. The mean age at diagnosis was 43 years (31-76 years). Six eyes corresponded to patients with acute myeloid leukaemia (AML), four eyes to acute lymphoid leukaemia (ALL), two eyes to chronic myeloid leukaemia (CML), and the remaining two belonged to patients with hairy cell leukaemia (HCL). The primary ocular findings were choroidal invasion in 12 eyes (85.7%), retinal infiltration in 4 eyes (28.6%), and neuro-ophthalmic disorders in 4 eyes (28.6%). The mean visual acuity improved from 0.689 to 0.449 (logMAR) (P=.012) after the systemic and intrathecal chemotherapy. Of the eight patients, four died from systemic complications of the underlying disease.

CONCLUSIONS

This is the first report of multiple ocular manifestations secondary to leukaemia in a Colombian population. It is important to keep in mind that this disease is included within the masquerade syndromes and that the ophthalmological findings that, while subtle, can also be devastating and be signs of a life-threatening disease.

Is prophylactic gastrectomy indicated for healthy carriers of CDH1 gene mutations associated with hereditary diffuse gastric cancer?

INTRODUCTION

hereditary diffuse gastric cancer (HDGC) is a recently reported hereditary cancer syndrome. Patients with suspected HDGC must be under surveillance via endoscopy and multiple biopsies. As an alternative, some studies suggest prophylactic gastrectomy (PG) for disease carriers. The goal of this article was to report our experience with a CDH1 mutation positive family who underwent PG.

PATIENTS AND METHODS

the index case was a 34-year-old female diagnosed with diffuse gastric adenocarcinoma and massive carcinomatosis. There was a family history of gastric adenocarcinoma in seven family members. A genetic study identified the c.1577G>A mutation, in exon 11 of the CDH1 gene via sequencing analysis.

RESULTS

this mutation was also present in other six family members, who subsequently underwent prophylactic gastrectomy. The pathology study of resected gastric segments revealed multiple microscopic foci of adenocarcinoma in five of these individuals. These foci were not detected in the multiple endoscopies performed before surgery.

CONCLUSIONS

we recommend prophylactic gastrectomy for CDH1 mutation carriers even in the absence of lesions during endoscopic screening.

Barrett's esophagus: "All diseases are divine and all are human"

Barrett's esophagus (BE) is a controversial condition. The significance of this condition lies in its premalignant potential, so it is important that clinically applicable biomarkers be identified for early detection and targeted prevention. Dysplasia is currently used as main biomarker, but others most recently surveyed in cancer also include microRNAs. Classically, BE was considered to be an acquired disease related to pathological gastroesophageal acid and bile reflux. However, some cases are associated with genetic predisposition, representing an inherited, familial form of BE. The actual gene, or genes, involved in this condition have not yet been identified. Main therapeutic options include medical treatment and antireflux surgery. Both types of treatment are equally efficient in controlling symptoms and neither is able to cause the metaplastic segment to disappear, which is why the risk of malignancy remains. However, we may use endoscopic radiofrequency to eradicate BE and replace it by the typical squamous epithelium of the esophagus. The currently accepted indications of radiofrequency in BE include low- and high-grade dysplasia, but not Barrett's esophagus without dysplasia. In conclusion, BE may have two different presentations: environmental ("human", reflux) or sporadic BE, which is the most common form, and genetic ("divine", inherited) or familiar BE, less common but with a greater risk for malignancy. As they might be two different diseases, surveillance programs and treatments should also be different.