Effect of weight loss induced by gastric bypass on proinflammatory interleukin-18, soluble tumour necrosis factor-alpha receptors, C-reactive protein and adiponectin in morbidly obese patients

OBJECTIVE

Interleukin-18 (IL-18) is a potent proinflammatory cytokine whose role in human obesity has recently been suggested. The aim of our study was to analyse in morbidly obese patients undergoing gastric bypass, the relationship of IL-18 with insulin resistance and with proinflammatory cytokines (tumour necrosis factor-alpha receptors, sTNFR), C-reactive protein (CRP) and with adiponectin.

DESIGN

Observational and prospective study.

PATIENTS

Sixty-five morbidly obese patients, aged 45 +/- 8.9 years, were studied before and 12 months after gastric bypass.

MEASUREMENTS

We analysed plasma concentrations of IL-18, sTNFR, CRP and adiponectin.

RESULTS

Plasma concentrations of sTNFR2, IL-18 and CRP were decreased and adiponectin significantly increased after bypass surgery. In the multiple regression analysis, preoperative values of IL-18 remained significantly associated with preoperative triglycerides (beta = 0.47, P = 0.005) and TNFR2 (beta = 0.47, P = 0.004). R(2) for the model = 0.38. Postoperative IL-18 concentrations in the multiple regression analysis were significantly associated with postoperative homeostasis model assessment of insulin resistance (HOMA-IR) (beta = 0.092, P = 0.019) and triglycerides (beta = 0.40, P = 0.036). R(2) for the model = 0.46. IL-18 did not correlate with body mass index, fat mass, fat-free mass or body fat. No relationship was either found between adiponectin and IL-18, TNFR1 and -2 and CRP.

CONCLUSIONS

Massive weight loss induced by gastric bypass reduces IL-18, TNFR2 and CRP. IL-18 might be a marker of the chronic inflammatory process underlying insulin resistance but its lack of association with anthropometric and body composition parameters does not support a major secretion by human adipocytes. IL-18 and sTNFR1 and -2 do not play a main role in the inhibition of the secretion of adiponectin.

Laparoscopic surgery in the elderly patient

BACKGROUND

Elderly patients represent a unique surgical challenge because of the associated complex comorbidity and diminished cardiopulmonary reserve. Therefore, minimally invasive surgery in the elderly may have a larger impact compared to the younger population. The aim of this study was to prospectively evaluate the experience of laparoscopic surgery in patients >or=70 years of age in our unit.

METHODS

Two hundred and thirty-two patients (34 females and 98 males) older than 70 years who underwent various elective and emergency laparoscopic procedures between 1992 and 1997 were assessed prospectively. Preoperative comorbidity, operative results, and postoperative outcomes were analyzed.

RESULTS

The median age of the patients was 76 years. The majority of patients were ASA class II. The mean hospital stay was 3.4 days. The overall morbidity and mortality rates were 10.8% and 3.4% respectively, and the conversion rate was 4.3%.

CONCLUSIONS

Our experience suggests that laparoscopic surgery in the elderly is safe, is associated with short hospital stay, and produces less morbidity and mortality. Therefore, it should be adopted widely if the expertise in the area of laparoscopic surgery is available for this group of patients.

Emergency laparoscopic treatment for acute massive bleeding of an esophageal ulcer

Laparoscopic fundoplication is now considered the treatment of choice for the management of severe gastroesophageal reflux disease (GERD) and its complications. The laparoscopic approach achieves the same good results as open surgery in elective surgery for GERD; it also has all the advantages of minimally invasive surgery. Today, laparoscopy plays also a significant role in a great variety of emergency abdominal situations and acute abdominal pain. A 30-year-old man was admitted to our center due to an upper gastrointestinal bleed caused by a esophageal ulcer over a Barrett's esophagus located in lower third of the esophagus. Two therapeutic esophagogastroscopies were done in 24 h, but urgent surgical intervention was indicated because of recurrent transfusion-demanding bleeding. A combined laparoscopic-endoscopic approach was followed. Surgery began with a complete hiatal dissection, including the distal third of the esophagus, diaphragmatic crus, and wide retrogastric window. Intraoperative flexible esophagoscopy revealed an active ulcer bleeding on the right anterior quadrant in the lower esophagus. Two transfixive stitches were applied through the wall of the esophagus at the site indicated by the light of the flexible endoscope, and complete hemostasis was achieved. Finally, employing the anterior wall of the fundus, a short Nissen-Rossetti fundoplication was performed. The operating time was 140 min. There were no complications and there has been no recurrence of the bleeding.

Results of the management of upper gastrointestinal bleeding from gastroesophageal varices

INTRODUCTION

The management of upper gastrointestinal bleeding caused by rupture of gastric and/or esophageal varices in patients with liver cirrhosis must focus on the initial control of the haemorrhage avoiding further worsening of an already poor liver function and the prevention of early relapsing bleeding. Therapeutic options include endoscopic, pharmacological and surgical methods.

MATERIAL AND METHODS

Prospective study of the results obtained after the follow-up of 90 bleeding episodes in a total of 54 patients, 35 men and 19 women, with a mean age of 58 years (range 32-77), to which a therapeutic protocol for acute bleeding secondary to portal hypertension was applied over a 22-months period. Patient classification according to Child-Pugh upon admission was 57% Child A, 34% Child B and 9% Child C.

RESULTS

Mean hospital length of stay was 9 days (2-50). Of the 90 bleeding episodes, 15 were early relapsing bleeding episodes (16.7%). Twelve patients died (mortality rate of 22.2% by patients and 13.4% by bleeding episodes). Twelve emergency surgical procedures were performed because of the persistence of haemorrhage. Forty one per cent of patients were readmitted because of relapsing bleeding at least once during the follow-up period.

CONCLUSIONS

Management of upper gastrointestinal bleeding due to gastroesophageal varices in patients with liver cirrhosis requires a combined therapy in order to attain maximum effectiveness in acute haemorrhagic episodes and to address all potential later consequences. Such therapy should be provided in a hospital fully equipped and with specialists in this pathology. Based on our experience, emergency surgery as rescue treatment for persistent or short-term relapsing bleeding should be restricted to patients with good hepatic function because of its high morbidity and mortality.

[Surgical treatment of emergency pathology of the left colon]

The aim of this study was to evaluate the postoperative morbidity and mortality of patients with left colon disease that underwent emergency surgery. Intra-operative colonic irrigation (ICI) with primary anastomosis was used for unresectable lesions, faecal peritonitis, colon remnant associated lesions and poor performance status. The options included colostomy, Hartmann procedure or subtotal colectomy; 127 resections of left-sided large bowel were performed. In 56 cases the procedure was a Hartmann operation, in 38 cases subtotal colectomy and in 33 ICI. The most frequent complication was abdominal sepsis (29%). The overall mortality was 24%; 39% for the Hartmann procedure; 16% for subtotal colectomy and 6% for ICI. Our results suggest that ICI should be the first choice in patients with good performance status who undergo emergency surgery for left colon disease without faecal peritonitis or associated right colon lesions.