Surgery and considerations for the repair of Petersen's space hernia after mini gastric bypass.

This paper reports a case of Petersen's space hernia after mini gastric bypass. This is an anecdotal post-operative complication in the mini gastric bypass technique, with an estimated rate of 1/5000 cases. Similar cases described in the literature were treated by the surgical hernia reduction and the closure of the mesenteric defect. Our patient had a unique management, performing a conversion to Roux-en-Y gastric bypass with dissection of the biliopancreatic limb at the anastomosis and creation of a variable foot-point anastomosis with excellent mid-term post-operative results. This should provide better long-term results as compared to simple mesenteric closure, avoiding the complications of mini gastric bypass technique.

Cirugía mínimamente invasiva de tumoración quística abdominal gigante en paciente puérpera / Minimally invasive surgery of a giant abdominal cyst tumor in a puerperal patient

La incidencia de masas anexiales diagnosticadas durante el embarazo varía según las diferentes series consultadas; sin embargo, masas de tamaño superior a 6 cm suponen casos excepcionales en la literatura. El manejo de este tipo de pacientes supone un reto para el equipo multidisciplinario, ya que se debe tener en cuenta el riesgo de cáncer de ovario en este tipo de pacientes. Se trata de una gestante de 34 años a la que se le diagnostica una masa anexial gigante durante el control ecográfico del primer trimestre. Ante la ausencia de sufrimiento fetal y teniendo en cuenta las características radiológicas de la lesión, se decide mantener una actitud expectante a la espera de un parto vía vaginal y poder realizar una cirugía electiva para la exéresis de la lesión. Tras el parto, la paciente sufre una anemización progresiva, por lo que se decide priorizar la intervención quirúrgica. Se llevó a cabo una exéresis de la masa mediante un abordaje mínimamente invasivo. Tanto la paciente como el recién nacido, tuvieron una evolución favorable. La paciente fue dada de alta tres días después de la cirugía(AU)

The incidence of adnexal masses diagnosed in pregnancy varies by the different consulted series; however, over 6cm long masses represent exceptional cases in literature. The management of this type of patients is a challenge for the multidisciplinary team since the risk of ovarian cancer should be taken into consideration in this type of patients. This is a 34 years-old pregnant patient who was diagnosed with giant adnexal mass during the echographic control of the first trimester. Due to the lack of fetal distress and the radiological characteristics of the lesion, it was decided to keep surveillance to wait for the vaginal delivery and to perform an elective surgery to remove the lesion. After the childbirth, the patient suffered a process of anemia, so it was decided to prioritize surgery. The mass was excised through a minimally invasive approach. Both the mother and the newborn had favorable recovery and the patient was discharged from hospital three days after surgery(AU)

Effect of bismuth subgallate on the quality of life in patients undergoing Scopinaro's biliopancreatic diversion.

BACKGROUND: Malabsorptive techniques, such as biliopancreatic diversion, described by Scopinaro, can cause disabling steatorrhea that affects patients' quality of life. Although it usually improves over time, a reduced group of patients can require treatment. The objective of the present study was to assess the effects of bismuth subgallate on the quality of life (QoL) of patients undergoing Scopinaro's biliopancreatic diversion (SBPD) for morbid obesity. The study was conducted at the Hospital Universitario Insular de Gran Canaria, Spain, a public hospital. METHODS: A prospective, observational study in clinical practice was performed to ascertain the effects of bismuth subgallate on QoL in a group of patients undergoing SBPD who reported disabling diarrhea and related odor. Patients received treatment with 2 courses of oral bismuth subgallate, 200 mg every 8 hours for 12 weeks, with a 4-week rest period. Pretreatment and posttreatment surveys were performed. The Gastrointestinal Quality of Life Index (GIQLI) questionnaire was used, which evaluates symptoms, physical status, emotional status, social performance, and treatment effects. RESULTS: Sixty patients--90% women--with a mean age of 45.6 years were included in the study, 65% of which had superobesity. GIQLI scores obtained at treatment completion were significantly higher--both overall and in the various domains--than those obtained before treatment onset (P<.01). When the morbid obesity and superobesity groups were analyzed separately, a significant increase in the scores for both patient groups was also observed (P< .01). CONCLUSIONS: In clinical practice, treatment with bismuth subgallate resulted in a short-term improvement of QoL for patients undergoing SBPD.

Right colon carcinoma infiltrating the alimentary limb in a patient with biliopancreatic diversion.

Biliopancreatic diversion (BPD) has excellent results, with the average patient losing 60% to 80% of the excess weight in the first 2 years. However, the BPD works by malabsorption and malabsorptive problems may be experienced with the operation. Therefore, monitoring is necessary for life. In the recent literature there is some debate over the possibility that this technique can increase the risk of colon cancer secondary to the action of the unabsorbed food and bile acid on colonic mucosa. We report the case of a 42-year-old patient with a previous bariatric surgery (BPD with 50 cm common channel; 300 cm alimentary limb) who developed a very aggressive right colon cancer 6 years after the operation. We also review our series of 330 patients operated on during a 14-year period to try to answer if there is any relationship between BPD and colon cancer.

Hypercalcemia associated with adenosquamous pancreatic carcinoma: a reason to initiate palliative treatment.

BACKGROUND: hypercalcemia in patients with diagnosed carcinoma has predominantly a humoral basis mediated by parathyroid hormone-related protein (PTH-rP). Among the reported cases, hypercalcemia associated with the majority of abdominal malignancies indicates an advanced stage of disease. CASE REPORT: we present a case of a 78-year-old patient with an adenosquamous pancreatic carcinoma associated with humoral hypercalcemia mediated by PTH-rP. CONCLUSION: in this case, demonstration of unexpectantly rapid increase in calcium serum correlated with aggressive tumor growth led us to raise the hypothesis that PTH-rP could be a mediator of invasion and dissemination secreted by some tumors, and probably indicates the appropriate time to initiate palliative treatment.

Remission of female sexual dysfunction in morbidly obese female patients with the Scopinaro procedure.

BACKGROUND: The prevalence of obesity has increased in Spain in recent years. Obese women are at increased risk for sexual dysfunction, and important remission of this condition has been previously reported with bariatric surgery. OBJECTIVES: The major aim of this study was to assess the effects of the Scopinaro biliopancreatic diversion on female sexual dysfunction (FSD) using a validated Female Sexual Function Index (FSFI). METHODS: Eighty sexually active women with morbid obesity and with FSD underwent surgery. All patients completed the FSFI before surgery, as well as 6 and 12 months after surgery. The FSFI evaluates the sexual function using 6 items: desire, arousal, lubrication, orgasm, satisfaction, and pain. We used a<26.5 cut-point to assess the presence of FSD. This cut-point is used as a standard for the investigation. RESULTS: Before surgery, all patients had FSD (mean 19.9±1.6). Six months after surgery, the FSD improved (mean 25.4±4.1; P<.001), and 12 months after surgery FSD resolved in most of the patients (mean 30.4±3.5; P<.001). All of the parameters evaluated by the FSFI (P<.001) improved significantly in all patients. CONCLUSION: FSD improved significantly 6 months after biliopancreatic diversion among obese women with preoperative sexual dysfunction and continued improving up to 12 months later.

Perforated gastrointestinal stromal tumor in Meckel's diverticulum treated laparoscopically.

Gastrointestinal stromal tumors (GIST) can represent a source of substantial gastrointestinal hemorrhage. Bleeding is described as a frequent cause of clinical presentation and commonly patients received surgical treatment on an urgent basis to drain the hematoma. However, a literature review has shown that perforation with peritonitis is very uncommon and rarely reported. These tumors are usually located in the stomach, and primary ileal and Meckel's localization is rare, occurring in less than 10% of cases in many series. In the English literature, we have found seven well-reported cases of GIST in a Meckel's diverticulum that presented with perforation and peritonitis; these case were found through a MEDLINE search of the terms: "perforated" GISTs in "Meckel's" GISTs. Herein, we describe a rare case of a perforated GIST in Meckel's diverticulum that caused severe peritonitis and that was treated with minimally invasive surgery.

Fistula to the native esophagus after pharyngogastrostomy for malignant disease: A rare phenomenon in esophageal surgery.

This article features the case study of a 32-year-old female patient who had undergone surgery to remove a cervical spine tumor and who later developed cervical esophagus necrosis secondary to the erosion caused by an osteosynthesis 13 years after her prosthetic cervical surgery. Barium swallow did not show anything abnormal, but after an emergency spiral computerized axial tomography (CAT) scan, a paravertebral abscess was found, along with displacement of the fixation plate and the disappearance of the esophageal silhouette on coronal sections. The patient underwent surgery to drain the abscess, extract the osteosynthesis materials and the stabilization plates, and to perform a temporary esophageal exclusion. Two months after this surgery the esophagus was reconstructed by performing a retrosternal pharyngogastrostomy without resection of the remaining cervicothoracic esophagus due to severe fibrosis and the absence of local recurrence. During the immediate post operatory period the patient developed a cervical fistula and after a month of conservative treatment, severe dysphagia was observed. Imaging tests showed a spontaneous fistula from the pharynx to the native esophagus, which prompted extraordinary treatment. Therefore, a jejunal loop was taken to the esophagus in the hiatus with a Roux-en-Y anastomosis to resolve this condition.

Intermuscular lipoma of the gluteus muscles compressing the sciatic nerve: an inverted sciatic hernia.

The authors report the case of a 50-year-old woman with a benign intermuscular lipoma of the gluteus compressing the sciatic nerve in its course through the sciatic notch. This benign soft-tissue tumor extended into the pelvis, displacing the rectum laterally. Resection was necessary to alleviate symptoms and prevent irreversible damage of the nerve. Wide exposure of the piriformis muscle and sciatic nerve via a transgluteal approach allowed safe lesion removal, and thus avoiding a laparotomy to resect the intrapelvic extension of the tumor. This report features a curious case of soft-tissue tumor growth across the sciatic foramen forming an inverted sciatic hernia. The authors' proposed approach was simple and safe and avoided a laparotomy.

[Staged oesophageal reconstruction for benign disease]. / Reconstrucción diferida del esófago tras su interrupción para el tratamiento de una patología benigna.

OBJECTIVES: To assess morbidity, mortality and quality of life after oesophageal reconstruction in patients with oesophageal exclusion for benign diseases. PATIENTS AND METHODS: From 2002 to 2011, 20 of 24 patients with esophageal exclusion due to benign disease underwent a delayed reconstruction. We analyzed morbidity, mortality and health-related quality of life using the SF-36 questionnaire, before and after reconstruction. RESULTS: Twenty patients were operated (16 men and 4 women) with an average age of 54.5 ± 10.5 years. Main causes of oesophageal disconnection were: 10 cases of caustics ingestion, 3 iatrogenic perforations, 4 anastomotic leaks and 3 cases with Boerhaave syndrome. Fourteen (60%) coloplasties and 6 (25%) gastric interpositions were performed with an average time of 212,2 ± 23.5 days after oesophageal exclusion. Pulmonary complications were the most common postoperative complications (55% patients) and according to the modified Clavien classification were divided into: grade 1 (10%), grade 2 (15%), grade 3a (40%), grade 3b (10%), and grade 4a (10%). The 30-day mortality (grade 5) of the series was 10%. Quality of life after reconstruction improved significantly in all analyzed domains of the SF-36 questionnaire. CONCLUSIONS: Deferred oesophageal reconstruction is associated with a high morbidity and a mortality rate of 10%. After reconstruction, the quality of life improved in all the parameters evaluated.

[Laparoscopic biliopancreatic diversion: a surgical technique in our learning curve]. / Derivación biliopancreática laparoscópica: técnica quirúrgica en nuestra curva de aprendizaje.

BACKGROUND: We present our initial experience with the laparoscopic BPD technique for super-obese patients. Recommended tips on the technique are summarized. METHODS: A total of 35 super-obese patients were submitted to BPD by laparoscopy in November 2009 and June 2010 for the treatment of morbid obesity. RESULTS: All operations were performed by laparoscopy with no need to convert to laparotomy. No mayor complications and mortality related to surgery were observed. CONCLUSION: The Scopinaro technique can be safely performed in super-obese patients by surgeons with special dedication for bariatric surgery and advanced skills in intracorporeal suturing and knot-tying.