Gastric ischemia secondary to intestinal occlusion due to gallstone ileus.

Gallstone ileus is a rare complication of cholecystoduodenal fistula. Gastric ischemia due to intestinal obstruction is an extremely rare event that, if not diagnosed in time, can have a fatal outcome. We present the case of a patient with intestinal occlusion due to a gallstone obstructing the middle jejunum in which gastric ischemia was diagnosed intraoperatively due to the distension caused by the intestinal obstruction.

Intraoperative radiotherapy with the Intrabeam® device for the treatment of resectable pancreatic adenocarcinoma. / Radioterapia intraoperatoria con Intrabeam® para el tratamiento del adenocarcinoma de páncreas resecable.

INTRODUCTION: The application of intraoperative radiation therapy to the tumor bed after resection of pancreatic cancer has been shown to be beneficial in the local control of the disease. The objective of this study was to evaluate the preliminary outcomes after the application of a single intraoperative dose to the tumor bed with a new intraoperative radiotherapy device (Intrabeam®) in terms of viability, safety and short-term results. METHODS: We studied 5 patients who underwent pancreaticoduodenectomy for resectable pancreatic cancer in which a radiotherapy boost (5Gy) was intraoperatively applied to the tumoral bed using the portable Intrabeam® device, a low-energy point-source X-ray. Postoperative complications, hospital stay and mortality, recurrences and short-term survival were analyzed. RESULTS: Mean patient age was 68 years. All patients had a T3-stage tumor and one of them N1. In 3 patients, R0 resection was performed, while R1 resection was conducted in 2. Perioperative mortality was 0%. The only complications included delayed gastric emptying and postoperative hemorrhage. There were no pancreatic fistulas. During follow-up (mean: 11.2 months), there was a relapse in the patient who had undergone R1 resection. CONCLUSIONS: The application of radiotherapy with the Intrabeam® device in selected patients has not resulted in increased perioperative morbidity or mortality; therefore, this is a safe procedure for the treatment of resectable cancer.

Obesity Surgery Score (OSS) for Prioritization in the Bariatric Surgery Waiting List: a Need of Public Health Systems and a Literature Review.

BACKGROUND: In the last decades, we have experienced an increase in the prevalence of obesity in western countries with a higher demand for bariatric surgery and consequently prolonged waiting times. Currently, in many public hospitals, the only criterion that establishes priority for bariatric surgery is waiting time regardless of obesity severity. METHODS: We propose a new, simple, and homogeneous clinical prioritization system, the Obesity Surgery Score (OSS), which takes into account simultaneously and equitably the time on surgical waiting list and the obesity severity based on three variables: body mass index, obesity-related comorbidities, and functional limitations. We have reviewed the current literature related to obesity clinical staging systems, and we have carried out an analysis of our patients in waiting list and divided their characteristics according to their degree of severity (A, B, or C) in the OSS. Patients with OSS grade C have a higher mean BMI, greater severity in comorbidities, and greater socio-labor impact. The current surgery waiting time of our series is of 26 months. Currently, 27 patients (51.9%) with OSS grade B and 15 patients (51.7%) with OSS grade C have been on our waiting list for more than 1 year. CONCLUSION: Since the obesity severity, the waiting time and its clinical consequences are associated with an increase in morbidity and mortality, it is important to apply a structured prioritization system for bariatric surgery waiting list. This allows prioritization of patients at greater risk, improves patient prognosis, and optimizes costs and available health resources.

[Predictive factors of massive intestinal necrosis in acute mesenteric ischemia]. / Factores predictivos de necrosis masiva intestinal en la isquemia mesentérica aguda.

INTRODUCTION: Suspicion of intestinal necrosis in patients with mesenteric ischemia is mandatory in surgery. Many patients develop massive necrosis after open surgery. However, in some frail, elderly patients, preoperative prediction of massive intestinal necrosis could avoid an unnecessary laparotomy. The aim of this study was to assess predictive factors of massive intestinal necrosis in acute mesenteric ischemia. PATIENTS AND METHOD: We retrospectively evaluated a consecutive sample of 155 patients, 88 men and 67 women, with a mean age of 71.9 years (SD +/- 13.6), who underwent surgery for acute mesenteric ischemia in our institution from 1990 to 2004. Age, sex, clinical features, laboratory findings, and delay to surgery were recorded and assessed as possible risk factors for massive intestinal necrosis. A logistic regression model was used to identify independent prognostic factors. RESULTS: Of the 155 patients, massive intestinal necrosis was recorded in 48 (31%; 95% CI: 23.4-38.6). A statistically significant association was found between massive intestinal necrosis and age (p = 0.04), previous digoxin use (p = 0.01), shock (p = 0.009), hemoconcentration (hemoglobin levels > 16 g/dL) (p = 0.02), hyperamylasemia (p < 0.001), acidosis (p = 0.012), and alkalosis (p = 0.048). Multiple stepwise logistic regression analysis identified three independent prognostic factors that were significantly associated with a higher risk of massive intestinal necrosis: shock (OR = 3.4; 95% CI: 1.1-10), hemoconcentration (OR = 6; 95% CI: 1.6-22.8), and hyperamylasemia (OR = 4.2; 95% CI: 1.5-12.2). CONCLUSIONS: Massive intestinal necrosis can be observed in at least 25% of patients undergoing surgery for acute mesenteric ischemia. Within the limitations of a retrospective study, the variables of shock, hemoconcentration and elevated serum amylase levels may be considered as independent predictive factors of fatal necrosis of the bowel.