[Influence of the lockdown due to COVID-19 on weight-loss results during the first year after sleeve gastrectomy]. / Influencia del confinamiento por COVID-19 en los resultados ponderales durante el primer año tras la gastrectomía vertical.

INTRODUCTION: COVID-19 pandemic has lead to lockdown of population in many countries. In Spain, the state of alarm was established from March 15 to June 20, 2020. Usually this fact decreased people's mobility and physical activity, in addition to producing or exacerbating psychological disorders. Our aim was to determine the influence that this condition had over the short-term ponderal results of patients undergoing laparoscopic vertical gastrectomy from May 2019 to May 2020. METHODS: Case-control study for comparing the percentage of excess weight lost (%EWL) and the percentage of total weight lost (%TWL) of patients that underwent a VG during the last year, so they were affected by lockdown in April and part of March 2020 (group 1), to the %EWL and %TWL of a control group (group 2), obtained from our previous series. RESULTS: The mean %EWL in group 1 is 47,37 ± 18,59 and in group 2 is 51,13 ± 17,59, being p = 0,438. Meanwhile, the mean %TWL in group 1 is 21,14 ± 8,17 and in group 2 is 24,67 ± 8,01, with p = 0,115. CONCLUSIONS: Population lockdown by COVID-19 did not get worse short-term results of vertical gastrectomy. More studies with a larger number of patients are necessary to draw firm conclusions.

Barrett's esophagus is a controversial condition.

We wish to respond to the comments provided by José Miguel Esteban López-Jamar and Ravishankar Asokkumar (1) about our report in this Journal (2). Some of the comments were perhaps prompted by inadequately explained or understood concepts, since they mention aspects that we never even considered or stated.

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.

Evolution of gastroesophageal reflux after laparoscopic vertical gastrectomy. A radiographic, manometric and pH-metric study.

INTRODUCTION: the relationship between laparoscopic vertical gastrectomy (LVG) and gastroesophageal reflux (GER) is still controversial. Therefore, its study is of great interest in order to obtain definitive conclusions. The goal of the study was to establish whether LVG modifies pH-metric GER in obese patients and to analyze the associated factors. PATIENTS AND METHODS: the first 26 patients who underwent LVG in our institution were enrolled in the study. A barium swallow, 24-hour ambulatory pH-metry and four-channel intraluminal esophageal manometry (IEM) were all performed before and one year after surgery. RESULTS: among the pH-metric data, there was a significant increase in the DeMeester index after the procedure (p = 0.028), while other parameters remained unchanged. Furthermore, 50% of patients with preoperative pH-metric GER had normal values at one year after surgery. IEM showed a decrease in lower esophageal sphincter (LES) pressure and in the mean wave amplitude at the distal third of the esophagus (p = 0.007 and p = 0.025, respectively). The rate of newly-developed hiatal hernias in the radiographic study was 36.4%. CONCLUSION: LVG mildly increases GER, which is likely related to the development of hiatal hernias and a decrease in LES pressure and esophageal sweep. However, LVG should not be contraindicated for patients with preoperative pH-metric GER, as this may clear after the procedure.

Histopathological and Immunohistochemical Analysis of the Use of Collagen Dressing as a Reinforcement of Esophagic Anastomosis in a Rat Experimental Model. / Análisis histopatológico e inmunohistoquímico del uso del apósito de colágeno como refuerzo de anastomosis esofágica en un modelo experimental en rata.

INTRODUCTION: One of the most severe complications after esophaguectomy is anastomotic dehiscence. The use of collagen sponges could be an effective way to resolve this complication. Our objective was to perform an experimental model of esophageal anastomosis in rats to study these mechanisms. METHODS: A total of 50 Sprague-Dawley rats were used divided into 2 groups, Tachosil® group (n=25) and control group (n=25). After the section of the abdominal esophagus a single-layer esophago-gastric anastomosis was performed reinforced with 1cm of Tachosil® wrapping the anastomosis in group 1. A functional study was performed using manometry as well as histopathological and immunohistochemical studies for angiogenic, fibrogenic and growth factors. RESULTS: The mortality in our series was 8% in the collagen dressing group, compared to 36% in the control group. When esophageal manometry was performed, the dehiscence pressure was higher in the reinforced anastomosis, On microscopical analysis, in the collagen dressing group a profuse inflammatory reaction with abundant neutrophils and macrophages surrounded by a connective matrix with fibroblasts and blood vessels was observed, The expression of VEGF, FGF1 and FGF2 was noticeably higher in the collagen dressing group. CONCLUSIONS: These results show that the application of collagen dressing facilitates tissue reparation phenomena, and therefore could be very useful as a reinforcement of esophago-gastric anastomosis to prevent dehiscence.

Communication between the obese patient and bariatric surgeon.

Communication between the bariatric surgeon and the obese patient is very important as it influences the expectations of patients with regard to surgery, aim of the surgery and the understanding of the mechanisms of failure of surgery. Furthermore, the incidence of certain psychopathology in these patients makes it necessary for the surgeon to have the ability to communicate to the patient the need for motivation and the maintenance of healthy life habits. Although the topic is subjective, in this article we review several useful recommendations to optimize communication before and after surgery. Finally, we emphasize the need to create workshops to train the bariatric surgeon in these issues that we consider so important.

Long-term follow-up of malignancy biomarkers in patients with Barrett's esophagus undergoing medical or surgical treatment.

OBJECTIVE: This study aims to compare some validated biomarkers of malignancy (Ki-67, p53, and apoptosis) between 2 groups of patients with Barrett's esophagus (BE) undergoing randomly medical or surgical treatment. BACKGROUND: The treatment of choice to prevent the malignant progression of BE remains controversial. Translational studies using biomarkers associated with the metaplasia-tumor pathway could be useful to provide some information in this regard. METHODS: The study group consisted of 45 patients: 20 under medical treatment with 40 mg/day of proton pump inhibitors (PPIs) and 25 after Nissen fundoplication (NFP). After a median follow-up of 8 years (range, 5-10 years), the values of Ki-67, p53, and apoptosis were analyzed in all patients before treatment (n = 45) and then 1 year (n = 45), 3 years (n = 45), 5 years (n = 45), and 10 years (n = 25) afterwards in both groups of treatment. These values were also analyzed in 2 subgroups of patients with successful medical and surgical treatment. RESULTS: Both Ki-67 and p53 remained stable after NFP, whereas they increased progressively in patients under PPIs with statistically significant differences between the 2 groups. Conversely, the apoptotic index increased progressively after NFP and decreased in the patients under PPIs with significant differences at 3, 5, and 10 years of follow-up. On comparing the subgroups of successful treatment the same differences were found. CONCLUSIONS: Barrett's epithelium remains more stable after a long-term follow-up in patients with BE treated surgically than in those under PPIs even in the absence of abnormal rates of acid reflux.

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.

[Evaluation of the aesthetic results perceived by patients after 3-port laparoscopic appendectomy]. / Valoración del resultado estético percibido por los pacientes apendicectomizados vía laparoscópica mediante tres incisiones.

INTRODUCTION: The aesthetic result has lately been used in General Surgery as an argument for the development of new approaches. On numerous occasions attempts have been made to evaluate the perception that the patients themselves have after their operation by whatever approach, with the aim of finding where we differ and if there is a real option for improvement. The objective of this study was to analyse, using a simple questionnaire, the assessment of the aesthetic results as perceived by patients after appendectomy, and to attempt to determine what are the variables involved in an aspect so subjective as this. PATIENTS AND METHOD: The variables collected were: age, sex, time since operation, infection of surgical wound, and presence of a drainage, as well as the responses on the aesthetic result of 70 patients who had a 3-port laparoscopic appendectomy. RESULTS: Infection of the surgical wound, as well as the age of the patients and the time since the operation determined statistically significant differences in their opinions as regards the number, size and overall aesthetic result of the laparoscopic appendectomy. The median overall satisfaction of the aesthetic result was 9 on a scale from 0 to 10. CONCLUSIONS: The assessment of the aesthetic result by patients after a 3-port laparoscopic appendectomy is good and is difficult to improve. It is recommended to prevent infection of the three ports after the intervention to obtain better results.

Influence of the lockdown due to COVID-19 on weight-loss results during the first year after sleeve gastrectomy.

INTRODUCTION: COVID-19 pandemic has lead to lockdown of population in many countries. In Spain, the state of alarm was established from March 15 to June 20, 2020. Usually this fact decreased people's mobility and physical activity, in addition to producing or exacerbating psychological disorders. Our aim was to determine the influence that this condition had over the short-term ponderal results of patients undergoing laparoscopic vertical gastrectomy from May 2019 to May 2020. METHODS: Case-control study for comparing the percentage of excess weight lost (%EWL) and the percentage of total weight lost (%TWL) of patients that underwent a VG during the last year, so they were affected by lockdown in April and part of March 2020 (group 1), to the %EWL and %TWL of a control group (group 2), obtained from our previous series. RESULTS: The mean %EWL in group 1 is 47.37±18.59 and in group 2 is 51.13±17.59, being P=.438. Meanwhile, the mean %TWL in group 1 is 21.14±8.17 and in group 2 is 24.67±8.01, with P=.115. CONCLUSIONS: Population lockdown by COVID-19 did not get worse short-term results of vertical gastrectomy. More studies with a larger number of patients are necessary to draw firm conclusions.

Results of the different surgical options for the treatment of cancer of the esophagogastric junction: Review of the evidence. / Resultados de las diferentes opciones quirúrgicas para el tratamiento del cáncer de la unión esofagogástrica. Revisión de la evidencia.

There is significant controversy in the management of cardiac cancer. It seems unanimous that Siewert type I tumors be operated on as cancer of the esophagus and Siewert type III as gastric cancer. However, for "true" cancer of the gastric cardia or Siewert II, the authors do not agree. There is the obvious need for free proximal and distal margins, as well as correct lymphadenectomy. For some, esophagectomy is necessary to perform correct radical oncological surgery, but other authors defend that an abdominal approach is sufficient to perform total gastrectomy and distal esophagectomy. Recent and older papers published do not clarify this issue, and their results are contradictory. Chemotherapy prior to surgery can reduce the size of the tumor and the presence of lymphadenopathies.

High risk of malignancy in familial Barrett's esophagus: presentation of one family.

Barrett's esophagus is an acquired condition fundamentally related to the presence of severe and prolonged pathologic acid and biliary gastro-esophageal reflux. However, genetic factors may also play a role in some cases. The aim of this study is to present 3 generations of a Spanish family with the largest number of members so far reported with Barrett's esophagus or esophageal adenocarcinoma. Of the 24 members of this family studied over 3 generations, 6 patients developed esophageal adenocarcinoma, 4 Barrett's esophagus, 6 clinical symptoms of gastro-esophageal reflux disease without Barrett's esophagus, and 8 were asymptomatic. In conclusion, patients with familial Barrett's esophagus get the disease more severely with a high rate of malignancy and, therefore, the endoscopic surveillance should be closer than in cases of nonfamilial Barrett's esophagus.

Role of self-expanding stents in the treatment of intrathoracic dehiscence after Ivor Lewis esophagectomy. / Papel de las endoprótesis autoexpandibles en el tratamiento de la dehiscencia intratorácica tras el procedimiento de Ivor Lewis.

INTRODUCTION: The role that self-expanding stents play in the treatment of dehiscence after transthoracic esophagectomy is not well defined and controversial. Our aim is to describe the experience in a tertiary care hospital using these devices for treating dehiscence after Ivor Lewis esophagectomy. METHODS: Descriptive observational study of patients who suffered anastomotic dehiscence after a transthoracic esophagectomy, and especially those treated with stents, in the period between 2011-2016 at our hospital. RESULTS: Ten patients (11.8%) presented anastomotic dehiscence. Eight patients received stents, one of them died due to causes unrelated to the device. Stent migration was observed in one case, and the devices were maintained an average of 47.3 days. The stent was not effective only in one patient who suffered early dehiscence due to acute ischemia of the stomach. The two patients who did not receive stents died after reoperation. CONCLUSIONS: Stents are safe and effective devices that did not associate mortality in our series. They are especially indicated in intermediate or late-onset dehiscence and in fragile patients. The use of stents, together with mediastinal and pleural drainage, avoid reoperations with morbidity and mortality. Therefore, stents should be part of the usual therapeutic arsenal for the resolution of most suture dehiscences after Ivor Lewis esophagectomy. Randomized prospective studies would help to more precisely determine the role played by these devices in the treatment of dehiscence after transthoracic esophagectomy.

[Splenic late infarction after laparoscopic gastrectomy: a case report]. / Infarto esplénico tardío tras gastrectomía vertical laparoscópica: a propósito de un caso.

INTRODUCTION: Laparoscopic gastrectomy has emerged in recent years as an effective technique for the treatment of morbid obesity due to low mortality morbidity rates. Its complications include dehiscence suture line, and others such as splenic infarction. We discuss a case of splenic infarction after laparoscopic gastrectomy. CLINICAL CASE: 45 year old male with a BMI of 37.8 kg/m2, diabetes-II for 15 years, the last five in treatment with insulin, a fasting blood glucose around 140mg/dl, HbA1c of 7.3mg/dl and microangiopathy diabetic nephropathy. The patient underwent a laparoscopic sleeve gastrectomy and he was discharged from hospital 48hours later. 1 month later he presented at the hospital for epigastric pain and fever up to 40° C. An intra abdominal abscess was detected and there was no leakage. The spleen was normal. He was treated with radiological drainage. 9 months later the patient consulted again due to epigastric pain in upper left quadrant, associated with low-grade fever. Thoraco-abdominal CT images compatible with splenic infarction. Currently patient remains asymptomatic one year after surgery. DISCUSSION: Laparoscopic sleeve gastrectomy is one of the most popular procedures of bariatric surgery. Less common complications include abscess and the splenic infarction. Usually patients are asymptomatic, but sometimes cause fever and pain. Initial treatment should be conservative. Only in selected cases, would splenectomy be indicated. CONCLUSIONS: Splenic infarction is usually an early complication, but we should keep it in mind as a long term complication for patients with persistent fever and abdominal pain after laparoscopic gastrectomy.