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.

Endoscopic treatment of postoperative esophagogastric leaks with fully covered self-expanding metal stents.

BACKGROUND: the management of postoperative esophageal leaks is a huge therapeutic challenge. Thanks to the advances in endoscopy, treatment with esophageal stents has been proposed as a valid option. AIMS: the main objective of the study was to evaluate the effectiveness and safety of the use of fully covered esophageal metal stents in the treatment of postoperative esophageal leaks. METHODS: a retrospective observational study was performed in patients with postoperative esophageal leaks, treated with fully covered self-expandable metal stents between June 2011 and May 2018. RESULTS: twenty-five patients were evaluated and 34 stents were placed. The closure of the leak was observed in 21 patients after removal of the stent, with an overall technical success rate of 84 %. The mean time with a stent placed for closure of the fistula was 55.7 ± 27.11 days/patient (mean of 39 ± 24.30 days/stent). The most frequent complication was a partial distal stent migration (7/34 stents), followed by five cases of complete migration into the stomach. CONCLUSIONS: endoscopic treatment with fully covered self-expandable metal stents seems to be an effective and safe first-line treatment for postoperative esophageal leaks, according to the experience in our center.

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.

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.

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.

Predictive value of MicroRNAs in the progression of barrett esophagus to adenocarcinoma in a long-term follow-up study.

OBJECTIVE: The aim of this study is to identify a set of microRNAs (miRNAs) as prognostic molecular biomarkers for the progression of Barrett esophagus (BE) to esophageal adenocarcinoma (EAC) to rationalize the surveillance programs in patients with BE. BACKGROUND: Histological dysplasia is currently used as the main biomarker to identify the BE patients at high risk for developing EAC. Although miRNA expression profiles in BE and EAC have been reported, it has not been established which set of miRNAs could constitute a robust diagnostic test to predict the progression of BE to EAC. METHODS: miRNAs associated with progression of BE to EAC were identified using miRNA sequencing analysis. Further validation by quantitative reverse transcription polymerase chain reaction (qRT-PCR) was performed in 2 groups of BE patients who either developed or did not develop adenocarcinoma after at least 5 years of follow-up. RESULTS: Twenty-three miRNAs were identified by miRNA sequencing analysis in the carcinogenesis process associated with BE. qRT-PCR analysis using independent tissue samples confirmed differential expression for 19 of them (miR-let-7c, 7, 146a, 149, 153, 192, 192*, 194, 194*, 196a, 196b, 200a, 203, 205, 215, 424, 625, 625*, and 944). However, only miR-192, 194, 196a, and 196b showed a significantly higher expression in BE samples from patients with progression to EAC compared with those who did not progress to EAC. CONCLUSIONS: These findings suggest that the expression pattern of a modest number of miRNAs in metaplasia biopsies could identify the BE patients at high risk for developing EAC. Therefore, it has potential use for the control and treatment of this malignancy.

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.

Activation of the BMP4 pathway and early expression of CDX2 characterize non-specialized columnar metaplasia in a human model of Barrett's esophagus.

BACKGROUND: A human model of gastroesophageal reflux disease was used to examine the contribution of a non-specialized columnar type of metaplasia (NSCM) and key molecular events (BMP4 and CDX2) in the development of Barrett's esophagus. METHODS: Biopsies of the remnant esophagus from 18 patients undergoing esophagectomy with gastric preservation were taken at 6-36-month intervals postoperatively and examined for activation of the BMP pathway (BMP4/P-Smad 1/5/8) and CDX2 and CDX1 expression by imunohistochemistry, quantitative real-time PCR, Western blot, and in situ hybridization. RESULTS: A short segment (mean 15.6 mm) of NSCM was detected in 10 (56%) patients, with an increasing prevalence from 17% at 6 months to 62% at 36 months. Nuclear expression of P-Smad 1/5/8 in the squamous epithelium close to the anastomosis with strong expression in all epithelial cells of NSCM areas was found. Forty-eight (63%) biopsies with NSCM showed scattered nuclear expression of CDX2. Two cases showed isolated glands at 18, 24, and 36 months that fully expressed CDX2 and co-expressed CDX1. BMP4 mRNA and CDX2 mRNA levels were significantly greater in NSCM than in squamous epithelium. CONCLUSIONS: BMP4 activation in NSCM and early expression of CDX2 are involved in the columnar epithelial differentiation of Barrett's esophagus.

[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.

[Outpatient monitoring of oesophageal pH with a catheter-free pH-meter (Bravo System). A Study of tolerance, safety and efficacy]. / Monitorización ambulatoria del pH esofágico con pH-metría sin sonda (sistema Bravo(R)). Estudio de tolerancia, seguridad y eficacia.

BACKGROUND AND OBJECTIVE: A new catheter-free outpatient oesophageal pH-meter system (Bravo) has recently been developed. The objective of this study is to test the tolerance, safety and efficacy of the system in the measurement of gastric-oesophageal reflux by comparing it with a conventional pH system. PATIENTS AND METHOD: The study was performed on a control group consisting of 10 healthy volunteers (group 1) and in a group of 40 patients with symptoms of gastric-oesophageal reflux disease (groups 2 and 3). An upper digestive system endoscopy, oesophageal manometry and oesophageal pH measurements with a conventional system and/or with the Bravo catheter-free system, was performed on all patients. All patients who had both tests done (groups 1 and 2) filled in a questionnaire on any physical problems and changes in their daily activity. RESULTS: The test tolerance was higher with the Bravo system in the 9 parameters studied. In the group of healthy volunteers (group 1), the median (range) of the total percentage of pH < 4 was 1.1% (0.5-3.1) with the conventional pH and 1.7% (0-3.4) with the Bravo. When comparing the patients with symptoms of gastric-oesophageal reflux disease (group 2) with those who had only one type of pH measurement made, the acid reflux was significantly higher in patients with Barrett's oesophagus than in the rest of the groups, with conventional pH as well as with the Bravo. If we analyse the patient group with disease due to gastric-oesophageal reflux with those on whom both techniques were used (group 3), 7 of the 10 patients had a pathological reflux that only showed up on measuring pH with the Bravo system. CONCLUSIONS: Catheter-free pH measurements (Bravo) is better tolerated and with better satisfaction for the healthy volunteers and patients than with conventional PH, even, on occasions being more efficient for studying acid reflux due to the lower incidence of negative results.

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.

Very long-term objective evaluation of heller myotomy plus posterior partial fundoplication in patients with achalasia of the cardia.

OBJECTIVE: To present the objectively assessed very long-term results of a prospective study of 149 patients with achalasia of the cardia who underwent Heller myotomy and posterior partial fundoplication. SUMMARY BACKGROUND DATA: Very few studies evaluate objectively the very long-term results to analyze whether the effectiveness of Heller myotomy is maintained with the passing of time. METHODS: The study group consisted of 149 patients who underwent a Heller myotomy plus a posterior partial fundoplication through a laparotomy. The median follow-up was 6 years (range, 1-27 years). Follow-up period was over 10 years in 53 patients and over 15 in 36. Clinical, radiologic, endoscopic, manometric, and pHmetric evaluations were performed postoperatively. RESULTS: Satisfactory results were higher than 90% up to 5 years. From that time on results gradually decreased to a 75% rate after 15 years (P < 0.001) due to either heartburn or dysphagia. Both the esophageal diameter and the mean resting pressure of the lower esophageal sphincter decreased postoperatively with no significant changes during follow-up. Esophagitis appeared in 11% of the patients (47% of them being asymptomatic) and 24-hour pH monitoring showed pathologic rates of acid reflux in 14% of patients, 58% of them being asymptomatic. Both esophagitis and pathologic rates of reflux appeared in >40% of the patients late in the follow-up. CONCLUSION: Results after Heller myotomy plus posterior partial fundoplication deteriorate with time, although we achieved a 75% of satisfactory results after >15 years of follow-up. Our study highlights the importance of life long follow-up and the objective assessment of the results.

[Surgical treatment of high-grade dysplasia in Barrett's esophagus]. / Tratamiento quirúrgico de la displasia de alto grado en el esófago de Barrett.

INTRODUCTION: Barrett's esophagus undergoes malignant transformation in 0.5-1% of patients per year following the sequence of low-grade dysplasia, high-grade dysplasia and adenocarcinoma. The aim of the present study was to present our experience in the surgical treatment of Barrett's esophagus with high-grade dysplasia. PATIENTS AND METHOD: Of a group of 128 patients with a diagnosis of Barrett's esophagus, 8 (6.2%) developed high-grade dysplasia during a median follow-up of 7 years (2-25). A further 5 patients with high-grade dysplaing out side the study were referred for evaluation and surgical treatment. Eight patients were under medical treatment with omeprazole (40 mg daily) while the remaining 5 patients had undergone open Nissen fundoplication, with a diagnosis of high-grade dysplasia at a median of 5 years (1-16) after treatment initiation. After confirmation of the diagnosis by a second pathologist and tumoral staging, transthoracic esophagectomy with anastomosis at the apex of the thorax was performed in all patients. RESULTS: Postoperative mortality was nil. Morbidity was 36% (5 patients). Definitive histological analysis of the surgical specimen revealed high-grade dysplasia in 7 patients (54%) and adenocarcinoma in 6 (46%). All patients remain alive after a median follow-up of 4.7 years (1-14). CONCLUSIONS: In patients with Barrett's esophagus with high-grade dysplasia, the best therapeutic option is surgical resection, which can be performed with nil mortality in experienced centers. In almost half of surgical patients, the surgical specimen shows adenocarcinoma. Five-year survival is higher than 90%.

Elevated basal calcitonin levels in a patient with a hurthle-cell carcinoma of the thyroid and neuroendocrine differentiation: report of a case.

A thyroid nodule with elevated plasma levels of calcitonin is usually suggestive of a medullary thyroid carcinoma (MTC); however, thyroid and extrathyroid conditions have been reported with elevated plasma calcitonin levels in the absence of MTC. We report the case of a patient with a thyroid nodule and an elevated basal plasma calcitonin level of 315 pg/ml (normal value <100 pg/ml) who underwent a left hemithyroidectomy. Interestingly, histopathological examination revealed a Hurthle-cell carcinoma with positive neuroendocrine (NE) markers such as calcitonin and synapthophysin, but not with chromogranin staining. Thus, we discuss the phenomenon of non-NE tumors showing positivity for NE markers.

Barrett's esophagus without esophageal stricture does not increase the rate of failure of Nissen fundoplication.

OBJECTIVE: To assess whether the presence of Barrett's esophagus (BE) modifies the results of Nissen fundoplication. SUMMARY BACKGROUND DATA: Some authors consider that BE, whether or not there is associated stricture, significantly increases the failure rate of standard antireflux surgery; they recommend using different and more aggressive surgical procedures in all patients with BE. METHODS: One hundred seventy-seven patients with gastroesophageal reflux disease, without esophageal stricture, were included in a retrospective study. Patients were divided into two groups: those with BE (n = 57) and those without BE (n = 120). Nissen fundoplication was performed in all patients by the same surgical team. Clinical, endoscopic, and functional (manometry and 24-hour pH monitoring) results in the two study groups were compared. RESULTS: After a median follow-up of 5 years (range 1-18) in the BE group and 6 years (range 1-18) in the non-BE group, the rate of clinical recurrence was 8% in the BE group and 10% in the non-BE group, with no statistically significant difference. The rate of pH-metric recurrence was the same in both groups (15%). CONCLUSIONS: The presence of BE without esophageal stricture does not increase the rate of failure of Nissen fundoplication.