1,721,016 research outputs found
"Evidence-based medicine: open and laparoscopic bariatric surgery" by Gentileschi et al., published in Surgical Endoscopy (2002) 16: 736-744.
No full textGentileschi et al. [1], in the article entitled ‘‘Evidence based medicine: open and laparoscopic bariatric surgery,’’ state that the only procedures proved to be highly effective on a long-term basis are open Roux-en-Y grastric bypass (RYGB) for morbidly obese and open longlimb RYGB (L-L RYGB) for superobese patients. RCTs are essential when comparing two procedures
whose outcome is predicted to be so similar that only
randomization can show the differences.
Bariatric operations (malabsorptive versus gastric
restrictive) have substantial differences in outcome, acknowledged by their authors. In particular, there is a
general consensus that biliopancreatic diversion (BPD)
is the most effective procedure. We see no rationale in
performing an RCT comparing BPD with another
procedure knowing in advance which one will yield the
best results. To assess worthiness in aerial combat of the
latest stealth fighter, you don’t need to compare it with a
World War I biplane. Furthermore, the level of standardization in obesity surgery is too low to perform a proper RCT. With
different surgeons performing the same operation differently and the number of other variables influencing the outcome in this particular surgery, the meaning of a single-institution RCT is that that specific operation, in the way it is performed by that specific surgeon, yields better results than another operation performed
by the same surgeon in his specific patient population. We see no reason in
questioning the use of a procedure that has earned its
establishment in over 25 years of clinical practice only
because of the existence of other procedures with different or unknown mechanisms of action and wellknown inferior results.
Not always is an RCT needed to determine what is
the ‘‘current best evidence’’ in making decisions about
the care of individual patients
Major hepatectomy with simultaneous pancreatectomy.
No full textI read with interest the article “Major Hepatectomy with Simultaneous Pancreatectomy for Advanced Hepatobiliary Cancer” by D’Angelica and colleagues. In their article, the authors submitted 17 patients to combined major hepatectomy with pancreatectomy (MHP), reporting considerable morbidity and mortality (mainly because of liver failure), but also unexpectedly good survival. It was interesting that mortality occurred only in patients in whom liver resection was associated with pancreaticoduodenectomy (PD). When hepatectomy was associated with resection of the tail of the pancreas, or was not concomitant to pancreatic resection (the latter operation being performed at a different time), no perioperative deaths occurred. There seems to be a relationship between severity of complications and type of pancreatic resection associated with hepatectomy, PD being the procedure carrying the highest risk. Hepatectomy and simultaneous pancreatectomy are performed in sizable numbers in Japan, with similar morbidity and mortality, although some authors report no mortality in fairly large series.
Major complications, possibly leading to death after MHP, are liver failure and anastomotic leakage. Insulin in the portal blood is an important hepatotrophic factor. It has potential to enhance mitochondria in hepatocytes and is necessary for liver regeneration after hepatectomy. Loss of pancreatic parenchyma may lead to decreased insulin production and impaired liver regeneration. It is not surprising that simultaneous hepatectomy and PD are associated with higher complication rates. Indeed, a study by Nagino and colleagues identified four variables independently associated with liver failure after extensive hepatic resection for biliary tumors: presence of cholangitis, abnormal oral glucose tolerance test, abnormal indocyanine green disappearance rate, and concomitant PD. To reduce the high rate of liver failure, the majority of Eastern authors use preoperative portal vein embolization (PVE), with the rationale of inducing liver hypertrophy before the pancreatic resection and the associated reduction of insulin production. Nimura and colleagues report a reduction in mortality after introduction of preoperative PVE in patients submitted to MHP. Regarding the high incidence of anastomotic leakage, Noie and colleagues suggest complete external drainage of pancreatic juice by means of a small-bore catheter cannulating the main pancreatic duct in high-risk patients, followed by second-stage pancreaticojejunostomy; they reported no postoperative mortality. The series by D’Angelica and colleagues is by far the largest ever reporting combined hepatectomy and pancreatectomy in Western patients, although also Doty and colleagues submitted 5 patients to pylorus-preserving pancreaticoduodenectomy and simultaneous liver resection for gallbladder cancer between 1996 and 1999
Effect of standard versus extended Roux limb length on weight loss outcomes after laparoscopic Roux-en-Y gastric bypass.
No full textGastric cancer and Roux-en-Y gastric bypass.
No full textIncidence of gastric cancer after Roux-en-Y gastric bypass
Unusual localization of visceral pain in peptic ulcer after biliopancreatic diversion.
No full textMarginal ulceration (MU) is a well recognized complication after gastric resection. It develops on the intestinal side of the gastroenteric anastomosis, the possible causes being a too large gastric pouch, inadequate mucosal blood flow, Helicobacter infection or NSAID use. Since May 1976, 2,316 patients underwent biliopancreatic diversion (BPD) for treatment of morbid obesity in our department. In BPD a distal gastric resection is done and the ileum 250 cm proximal to the ileocecal valve is anastomosed to the proximal gastric remnant. MU is an infrequent but annoying complication after BPD. Its incidence in our series is today
3.4%, most ulcers (67%) appearing during the first
postoperative year. Stomal ulcer is more frequent
in men and is strongly influenced, especially in
women, by alcohol ingestion and by cigarette consumption. It usually responds well to medical treatment (94% healing with H2 blocker therapy), and it has no tendency to recur except in smokers
Biliopancreatic diversion causes remission of type 2 diabetes mellitus in persons with BMI < 35 kg/m2
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