First, we would like to congratulate the authors of this study1 for stimulating reflection on public health policy involving the diagnosis of colorectal cancer (CRC), a topic of extreme relevance, given that it is the third most common cancer in men and the second most common cancer in women. In 2020, there were more than 1.9 million new cases of CRC6.
The benefits of CRC screening were recognized four decades ago when the American Cancer Society started recommending it. The screening was responsible for the decline in CRC incidence observed since the 1980s2.
Randomized studies have shown that screening people at medium risk, that is, those with no family history of CRC, reduces the incidence and mortality resulting from this neoplasm2,3.
In contrast to screening programs for other neoplasms, CRC screening allows the diagnosis of lesions at an early stage and the detection of pre-malignant lesions that, if removed, can prevent cancer4.
The importance of CRC screening is based not only on the possibility of early diagnosis but also on the impact of endoscopic polypectomy, which reduces mortality related to this neoplasm by more than 50%7.
The comments below discuss the methodology used in the study (NordiCC Study) and the negative impact on a diagnostic technique established in several publications due to structural errors added to the article.
Pragmatic (real-life) randomized controlled trials (RCTs) can be considered observational studies (cohorts) in which, although randomization is present, it does not give these trials the character of experimentation (associated with the term randomized clinical trial) – the rigorous individual eligibility criteria are a fundamental part of the methodology. Even when these eligibility criteria are “relaxed,” the analysis in these (pragmatic) trials must necessarily consider prognostic differences between participants, which are essential to avoid confounding and selection bias. In addition, the term pragmatic may be misused as the cohort departs from usual practice because, despite the randomization of participants being performed at the group level, the proposed interventions do not correspond to the conventional care that these patients would receive, as an invitation for colonoscopy, periodic contact, or even the creation of a control group without care (called usual care). Also, the absence of care in the usual care group (comparison) calls into question the classic concept of randomization since there is no control in this group regarding losses or migration (crossover) to colonoscopy.
Intention-to-treat analysis is prohibitive due to the extensive loss of adherence (non-compliers) of participants in the invited (screened) group, decreasing the sample in this group after randomization by more than 50%. The only possible analysis is per protocol. Furthermore, non-complier patients (who did not accept the invitation) and conventional care patients should be analyzed within the same group (not screened) and compared with participants who actually underwent colonoscopy.
Although bariatric surgery is today’s gold standard treatment for obesity, weight regain affects the success rate of the procedure. Recent studies have identified psychiatric and neurological factors as possible causes.
The aim of this study was to evaluate the influence of psychiatric diseases on the outcome and long-term success of bariatric surgeries and find a weight regain threshold that has an acceptable sensibility to mental health-related issues to be used in research and clinical studies.
This is a observational study of bariatric patients submitted to Roux-en-Y bypass or sleeve gastrectomy, with a postoperative time of 2–10 years to access weight regain, depression, and binge-eating disorder.
Of 217 patients studied, 163 were women and 54 were men, with an average postoperative time of 5.2±2.6 years. Weight regain was experienced in 35% of the patients, binge-eating disorder in 24.9%, and depression in 24%. The greater weight before surgery, body mass index (BMI), percentage increase to maximum weight loss, and time postoperatively all have a significant positive correlation with weight regain (p=0.045, p=0.026, p<0.001, and p<0.001, respectively). A significant association between binge-eating disorder, depression, and anxiety with weight regain (p=0.004, p=0.008, and p=0.001, respectively) was found.
The significant weight regain rates with significant impact on psychiatric disorders highlight the need for continuous postoperative monitoring focused on the psychiatric aspects of obesity to aid surgeries’ long-term success.
Nowadays, non-alcoholic fatty liver disease (NAFLD) is considered one of the most important causes of chronic liver disease in the world. Recent data show a global prevalence of 25%, with a recent increase that follows the current trends of the obesity epidemic13. Among obese patients, the prevalence of NAFLD can exceed 90%4,10. NAFLD is a spectrum of disease involving simple hepatic steatosis and nonalcoholic steatosis (NASH) with or without fibrosis or cirrhosis.
Regarding the disease’s natural history, about 20% of patients with hepatic steatosis have NASH. Over time, 20% of those individuals will develop hepatic cirrhosis. Recently, NASH had become the most important indication of liver transplant among women in the United States and is expected to overtake alcoholic liver disease as the leading liver transplant indication for all patients within the next few years. Compared to NAFLD, patients with NASH can develop hepatocellular carcinoma in a 12 times higher rate and have an annual mortality 1.7 times higher9.
Liver biopsy is the only method to diagnose NASH. It is histologic demonstrations of hepatic steatosis associated with hepatocyte ballooning degeneration and lobular inflammation. There are some clinical scores for prediction of liver fibrosis; however, these methods were not validated for the obese population and present variable specificity and sensibility in the literature3,10,11.
De Carli et al.3 evaluated the performance of these noninvasive scores in morbidly obese patients undergoing bariatric surgery. They found that the APRI (AST to platelet ration index) presented the higher specificity (99.61%), predictive positive value (PPV) (85.71%), positive likelihood ratio (PLR) (62.5), and accuracy (0.93). FIB4 was the second test in terms of accuracy (0.9) and PLR (10.53). Udelsman et al.11, in contrast, evaluated liver biopsies of 2465 obese patients and reported that the NAFLD fibrosis score (NFS) performed best in screening out advanced fibrosis, with a sensitivity of 85% and an NPV of 99%.
In that regard, the American Society of Bariatric and Metabolic Surgery (ASBMS) recently proposed an algorithm for screening for advanced liver fibrosis in patients seeking bariatric surgery8. According to the authors, it is possible to rule out advanced fibrosis in one-third of the patients undergoing bariatric surgery. In other words, if the score is under the cutoff value of -1.455, they do not to recommend performing a liver biopsy intraoperatively. In patients with indeterminate or high NFS, liver stiffness measure or intraoperative liver biopsy should be considered.
However, we must emphasize that NAFLD is a variable spectrum of disease, which reduces the accuracy of clinical scores and makes it difficult to identify specific markers for screening for the disease. The condition also has a major burden in the public health system due to its natural history and negative outcomes. Therefore, in the context of bariatric surgery, it is very important to screen the patients for advanced fibrosis and cirrhosis, since it may alter the follow-up and treatment after surgery. Intraoperative liver biopsy is relatively safe because it is possible to observe and confirm hemostasis, unlike percutaneous needle biopsy12. We also believe that the additional operative time (around 5 min) and the cost of processing the specimen do not overcome the potential benefits of an accurate diagnosis.
There are no NASH-specific medications. Weight loss is the first treatment goal if it has the strongest association with histologic improvement1,2. Currently, bariatric surgery is the most effective weight-loss therapy, which plays a crucial role in the management of obese patients with NAFLD and NASH. Studies comparing liver biopsies before and after bariatric surgery have shown substantial improvements in liver histology, including fibrosis regression5–7.
The NAFLD inflicts a great burden on patients’ and on the health system. As long as we do not find an accurate biochemical marker or clinical score, intraoperative liver biopsy remains the best alternative for an adequate diagnosis in patients undergoing bariatric surgery. It allows the proper follow-up and treatment after the surgery. Routine hepatic biopsy during surgery makes possible to both the physician and the patient to know the real extent of the problem and manage it properly. The high prevalence of NAFLD in this population overcomes any possible complications or extra cost of the procedure.
Although bariatric surgery is highly effective for the treatment of obesity and its comorbidities, preoperative weight loss has an impact on its results.
Although bariatric surgery is highly effective for the treatment of obesity and its comorbidities, preoperative weight loss has an impact on its results.
The aim of this study was to correlate preoperative weight loss with the outcome of bariatric surgery using the Bariatric Analysis and Reporting Outcome System scores.
This is a cross-sectional, observational study with 43 patients undergoing bariatric surgery that compared a group of 25 patients with a percentage of preoperative excess weight loss ³8% with a group of 18 patients with a percentage of preoperative excess weight loss <8% or with weight gain. The research took place at the bariatric surgery outpatient clinic of the Oswaldo Cruz University Hospital with patients 1 year after the surgery.
Patients had a mean age of 40.8 years (42.7 percentage of preoperative excess weight loss ≥8% vs. 38.2 percentage of preoperative excess weight loss <8%, p=0.095). No significant difference was found between the two groups regarding preoperative comorbidities and body mass index at entry into the program. Higher preoperative body mass index (48.69 vs. 44.0; p=0.029) was observed in the group with percentage of preoperative excess weight loss <8%. No significant difference was found regarding the percentage of excess weight loss (71.4±15.4%; percentage of preoperative excess weight loss ≥8% vs. 69.47%±14.5 percentage of preoperative excess weight loss <8%; p=0.671), the result of the surgery according to the Bariatric Analysis and Reporting Outcome System scores protocol, the resolution of comorbidities, the quality of life, and the surgical complications between the two groups.
Based on the available data, it is reasonable that bariatric surgery should not be denied to people who have not achieved pre-established weight loss before surgery.
Bishop-Koop ileostomy has been widely used in pediatric patients with the intention of including as much bowel as possible in the intestinal transit early in the management of children with meconium ileus and intestinal atresia. In recent years, we have been using it as an alternative to test the distal bowel function before closure of a previously constructed ostomy in selected children with questionable distal bowel motility.
The aim of this study was to present our experience with this alternative use of the Bishop-Koop ostomy.
This is a cross-sectional retrospective review of hospital records, combined with a comprehensive literature review.
Seven children were included: five had suspected aganglionosis, one had gastroschisis complicated with ileal atresia, and one had a colonic stricture secondary to necrotizing enterocolitis. In this short series of patients, motility of the distal bowel was correctly assessed in six patients and partially correctly assessed in one patient. One patient did not pass stools per anus after the Bishop-Koop, and he was later confirmed to have Hirschsprung disease. Four patients resumed normal evacuation pattern after closure of the Bishop-Koop. One patient had a Bishop-Koop colostomy because of recurrent enterocolitis after a transanal pull-through. Although he evacuated normally while having the colostomy, the diarrhea recurred after the ostomy was closed. An additional patient, with a severe behavioral problem, did not evacuate per anus after her colostomy was transformed in a Bishop-Koop-type ostomy, despite the apparent presence of normal ganglia in the bowel wall.
Data from the present series allow us to affirm that Bishop-Koop-type ostomy is a safe and efficient procedure that can be used to assess distal bowel function before a definitive transit reconstruction, in children with uncertain motility issues.
Laparoscopic surgery has been increasingly applied to gastric cancer surgery. Gastrointestinal tract reconstruction totally done by laparoscopy also has been a challenge for those who developed this procedure.
- To describe simplified reconstruction after total or subtotal gastrectomy for gastric cancer by laparoscopy and the results of its application in a series of cases.
- In the last four years, 75 patients were operated with gastric cancer and two with GIST. Thirty-four were women and 43 men. The age ranged from 38 to 77 years with an average of 55 years. In two patients with GIST a total and a subtotal gastrectomy were performed. In the other 75 patients were done 21 total gastrectomies and 54 subtotal. In all cancers, gastrectomy with D2 lymphadenectomy was completed with at least 37 lymph nodes removed. Was used in these operations a modified laparoscopic technique proposed by the authors consisting in a latero lateral esophagojejunal anastomosis with linear stapler in TG as well in STG, and reconstruction of the digestive continuity also in the upper abdomen.
- The intraoperative and immediate postoperative course were uneventful, except for one case of bleeding due to an opening clip, necessitating re-intervention. The operative time was 300 minutes, with no difference between total or subtotal gastrectomy. The number of lymph nodes removed varied from 28 to 69, averaging 37. Postoperative staging showed one case in T4 N2 M0; 13 in T2 N0 MO; 27 in T2 N1 M0; 24 in T3 N1 M0 and 10 in T3 N2 M0. Complication in only one case was observed on the 10th postoperative day with a small anastomotic leakage in esophagojejunal anastomose with spontaneous closure.
- The patient's evolution with no complications, no mortality and just one small anastomotic leakage with no systemic repercussions is a strong indication of the liability and feasibility of this innovative technical method.
Gallbladder carcinoma presents a dismal prognosis. Choice treatment is surgical resection that is associated a high levels of both morbidity and mortality. Best knowledgement of prognostic factors may result a better selection of patients either for surgical or multimodal treatment.
To evaluate tecidual immunoexpression of P53, E-cadherin, Cox-2, and EGFR proteins and to correlate these findings with resected gallbladder adenocarcinoma survival.
Clinical, laboratorial, surgical, and anatomopathological reports of a series of gallbladder adenocarcinoma patients were collected by individualized questionary. Total sample was 42 patients. Median of age was 72 years (35-87). There were seven men and 35 women. Lesion distribuition in according TNM state was the following: T1 (n=2), T2 (n=5), T3 (n=31), T4 (n=4). Twenty-three patients underwent radical resection (R0), while 19 palliative surgery (R1-R2). A block of tissue microarray with neoplasic tissue of each patient was confected. It was performed evaluation of P53, E-Caderine, COX-2, and EGFR proteins imunoexpression. These findings were correlated with overall survival.
Five-year survival was 28%. The median of global survival was eight months. Only immunoexpression of EGFR protein was considered independent variable at multivariated analysis.
Final prognosis was influenced by over-expression of EGFR protein in tumoral tissue.
Some studies have suggested that preoperative chemotherapy for hepatic colorectal metastases may cause hepatic injury and increase perioperative morbidity and mortality.
To evaluate the prevalence of hepatic steatosis in patients undergoing preoperative chemotherapy for metastatic colorectal cancer.
Observational retrospective cohort study in which 166 patients underwent 185 hepatectomies for metastatic colorectal cancer with or without associated preoperative chemotherapy from 2004 to 2011. The data were obtained from a review of the medical records and an analysis of the anatomopathological report on the non-tumor portion of the surgical specimen. The study sample was divided into two groups: those who were exposed and those who were unexposed to chemotherapy.
From the hepatectomies, 136 cases (73.5%) underwent preoperative chemotherapy, with most (62.5%) using a regimen of 5-fluorouracil + leucovorin. A 40% greater risk of cell damage was detected in 62% of the exposed group. The predominant histological pattern of the cell damage was steatosis, which was detected in 51% of the exposed cases. Exposure to chemotherapy increased the risk of steatosis by 2.2 fold. However, when the risk factors were controlled, only the presence of risk of hepatopathy was associated with steatosis, with a relative risk of 4 (2.7-5.9).
Patients exposed to chemotherapy have 2.2 times the risk of developing hepatic steatosis, and its occurrence is associated with the presence of predisposing factors such as diabetes mellitus and hepatopathy.
Cholelithiasis is prevalent surgical disease, with approximately 60,000 admissions per year in the Unified Health System in Brazil. Is often asymptomatic or oligosymptomatic and major complications arise from the migration of calculi to low biliary tract. Despite these complications are severe and life threatening, some patients refuse surgical treatment.
To understand why individuals with cholelithiasis refuse cholecystectomy before complications inherent to the presence of gallstones in the bile duct and pancreatitis occur.
To investigate the universe of the justifications for refusing to submit to surgery it was performed individual interviews according to a predetermined script. In these interviews, was evaluate the knowledge of individuals about cholelithiasis and its complications and the reasons for the refusal of surgical treatment. Were interviewed 20 individuals with cholelithiasis who refused or postponed surgical treatment without a plausible reason. To these interviews, was applied the technique of thematic analysis (Minayo, 2006).
The majority of respondents had good knowledge of their disease and its possible complications, were well oriented and had surgical indications by their physicians. The refusal for surgery was justified primarily on negative experiences of themselves or family members with surgery, including anesthesia; fear of pain or losing their autonomy during surgery and postoperative period, preferring to take the risk and wait for complications to then solve them compulsorily.
The reasons for the refusal to surgical resolution of cholelithiasis were diverse, but closely related to personal (or related persons) negative surgical experiences or complex psychological problems that must be adequately addressed by the surgeon and other qualified professionals.
Colorectal cancer is a major cause of morbidity and mortality and can arise through the adenoma-carcinoma sequence. Colonoscopy is considered the method of choice for population-wide cancer screening.
To assess the characteristics of endoscopically resected polyps in a consecutive series of patients who underwent colonoscopy at a university hospital and compare histopathology findings according to patient age and polyp size.
Retrospective, cross-sectional of 1950 colonoscopy reports from consecutively examined patients. The sample was restricted to reports that mentioned colorectal polyps. A chart review was carried out for collection of demographic data and histopathology results. Data were compared for polyps sized ≤0.5 cm and ≥0.6 cm and then for polyps sized ≤1.0 cm and ≥1.1 cm. Finally, all polyps resected from patients aged 49 years or younger were compared with those resected from patients aged 50 years or older.
A total of 272 colorectal polyps were resected in 224 of the 1950 colonoscopies included in the sample (11.5%). Polyps >1 cm tended to be pedunculated (p=0.000) and were more likely to exhibit an adenomatous component (p=0.001), a villous component (p=0.000), and dysplasia (p=0.003). These findings held true when the size cutoff was set at 0.5 cm. Patients aged 50 years or older were more likely to have sessile polyps (p=0.023) and polyps located in the proximal colon (p=0.009). There were no significant differences between groups in histopathology or presence of dysplasia.
Polyp size is associated with presence of adenomas, a villous component, and dysplasia, whereas patient age is more frequently associated with sessile polyps in the proximal colon.
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