Impact of tumor stage and neoadjuvant chemotherapy in fluorescence-guided lymphadenectomy during laparoscopic gastrectomy for gastric cancer: A propensity score-matched study in a western center.

BACKGROUND: The use of indocyanine green fluorescence has been shown to be a safe and effective method for improving lymph node retrieval in patients with gastric cancer. However, previous studies have focused on early-stage tumors and/or the Asian population and excluded patients who received neoadjuvant treatment. METHODS: In this study, 142 patients with gastric adenocarcinoma underwent laparoscopic gastrectomy at a Spanish hospital between January 2017 and December 2022. Of these, 42 patients received preoperative indocyanine green injection to guide lymphadenectomy. Their outcomes were compared to a retrospective cohort of 42 patients after 1:1 propensity score matching. RESULTS: The feasibility of indocyanine green lymphatic mapping was 95.5%. No complications associated with indocyanine green injection were observed. The indocyanine green group had a significantly higher number of retrieved lymph nodes than the non-indocyanine green group (32.67 vs 25.14; P = .013). This statistically significant difference was maintained across subgroups of neoadjuvant treatment, non-obese patients, pT0 to 2 stage, and pN0 stage. In 47.6% of patients from the indocyanine green group, lymphadenectomy was extended outside the standard D2 dissection area based on indocyanine green uptake, but none of the retrieved lymph nodes were metastatic. There were no differences in postoperative complications and length of hospital stay between the 2 groups. CONCLUSION: Indocyanine green-guided lymphadenectomy is safe and feasible and increases the number of retrieved lymph nodes compared to conventional lymphatic dissection, as well as in patients receiving neoadjuvant chemotherapy. The use of indocyanine green should be routine if available for guiding lymph node dissection in gastric cancer, regardless of tumor stage or previous neoadjuvant treatment. However, further studies are needed to determine the impact of this technique on disease-free and overall survival.

Prognostic factors of weight loss after sleeve gastrectomy: Multi centre study in Spain and Portugal. / Factores predictivos de pérdida ponderal tras la gastrectomía vertical. Estudio multicéntrico hispano-portugués.

INTRODUCTION: Sleeve gastrectomy (SG) has become a technique in its own right although a selective or global indication remains controversial. The weight loss data at 5 years are heterogeneous. The aim of the study is to identify possible prognostic factors of insufficient weight loss after SG. METHODS: A SG retrospective multicenter study of more than one year follow-up was performed. Failure is considered if EWL>50%. Univariate and multivariate study of Cox regression were performed to identify prognostic factors of failure of weight loss at 1, 2 and 3 years of follow up. RESULTS: A total of 1,565 patients treated in 29 hospitals are included. PSP per year: 70.58±24.7; 3 years 69.39±29.2; 5 years 68.46±23.1. Patients with EWL<50 (considered failure): 17.1% in the first year, 20.1% at 3 years, 20.8% at 5 years. Variables with influence on the weight loss failure in univariate analysis were: BMI>50kg/m2, age>50years, DM2, hypertension, OSA, heart disease, multiple comorbidities, distance to pylorus> 4cm, bougie>40F, treatment with antiplatelet agents. The reinforcement of the suture improved results. In multivariate study DM2 and BMI are independent factors of failure. CONCLUSION: The SG associates a satisfactory weight loss in 79% of patients in the first 5 years; however, some variables such as BMI>50, age>50, the presence of several comorbidities, more than 5cm section of the pylorus or bougie>40F can increase the risk of weight loss failure.

Quality criteria in bariatric surgery: Consensus review and recommendations of the Spanish Association of Surgeons and the Spanish Society of Bariatric Surgery. / Criterios de calidad en cirugía bariátrica: revisión de conjunto y recomendaciones de la Asociación Española de Cirujanos y de la Sociedad Española de Cirugía de la Obesidad.

Bariatric surgery has proven to be highly effective in controlling obesity and metabolic syndrome; the results of this surgery are not only expressed in terms of weight loss, but also in terms of resolution of comorbidities, improved quality of life and complications. The different parameters used to measure these outcomes require uniformity and reference patterns. Therefore, it is essential to identify those indicators and quality criteria that are helpful in defining the «best practice¼ principles in bariatric surgery. In this regard, the Section of Obesity of the Spanish Association of Surgeons, in collaboration with the Spanish Society for Bariatric Surgery (SECO), present as an objective to identify the key points that define «quality¼ in this type of surgery. We describe the main indicators based on the published literature as well as the criteria for referral of the main comorbidities according to the evidence found and grades of recommendation.

Laparoendoscopic Single-Site Cholecystectomy: First Experiences with a New Standardized Technique Replicating the Four-Port Technique.

BACKGROUND: After reports on laparoendoscopic single-site (LESS) cholecystectomy, concerns have been raised over the level of difficulty and a potential increase in complications when moving away from conventional gold standard multiport laparoscopy due to incomplete exposure and larger umbilical incisions. With continued development of technique and technology, it has now become possible to fully replicate this gold standard procedure through an LESS approach. First experiences with the newly developed technique and instrument are reported. METHODS: Fifteen patients presenting with cholelithiasis without signs of inflammation were operated using all surgical steps considered appropriate for the conventional four-port laparoscopic approach, but applied through a single access device. Operation-centered outcomes are presented. RESULTS: There were no peri- or postoperative complications. Mean operating time was 32.3 minutes. No conversion to regular laparoscopy was required. The critical view of safety was achieved in all cases. Mean skin incision length was 2.2 cm. CONCLUSION: The application of a standardized technique combined with the use of a four-port LESS device allows us to perform LESS cholecystectomy, giving us a correct exposure of the structures and without increasing the mean operating time combining previously reported advantages of LESS. A universal trait of any new technique should be safety and reproducibility. This will enhance its applicability by large number of surgeons and to large number of patients requiring cholecystectomy.

Prognostic Factors for Morbimortality in Sleeve Gastrectomy. The Importance of the Learning Curve. A Spanish-Portuguese Multicenter Study.

BACKGROUND: Complications in sleeve gastrectomy (SG) can cast a shadow over the technique's good results and compromise its safety. The aim of this study is to identify risk factors for complications, and especially those that can potentially be modified to improve safety. METHODS: A retrospective multicenter cohort study was carried out, involving the participation of 29 hospitals. Data was collected on demographic variables, associated comorbidities, technical modifications, the surgeon's experience, and postoperative morbimortality. A multivariate logistic regression analysis was carried out on risk factors (RFs) for the complications of leak/fistula, hemoperitoneum, pneumonia, pulmonary embolism, and death. RESULTS: The following data were collected for 2882 patients: age, 43.85 ± 11.6. 32.9 % male; BMI 47.22 ± 8.79; 46.2 % hypertensive; 29.2 % diabetes2; 18.2 % smokers; bougie calibre ≥40 F 11.1 %; complications 11.7 % (2.8 % leaks, 2.7 % hemoperitoneum, 1.1 % pneumonia, 0.2 % pulmonary embolism); and death 0.6 %. RFs for complications were as follows: surgeon's experience < 20 patients, OR 1.72 (1.32-2.25); experience > 100 patients, OR 0.78 (0.69-0.87); DM2, OR1.48(1.12-1.95); probe > 40 F, OR 0.613 (0.429-0.876). Leak RFs were the following: smoking, OR1.93 (1.1-3.41); surgeon's experience < 20 patients, OR 2.4 (1.46-4.16); experience of 20-50 patients, OR 2.5 (1.3-4.86); experience >100 patients, OR 0.265 (0.11-0.63); distance to pylorus > 4 cm, OR 0.510 (0.29-0.91). RFs for death were as follows: smoking, OR 8.64 (2.63-28.34); DM2, OR 3.25 (1.1-9.99); distance to pylorus < 5 cm, OR 6.62 (1.63-27.02). CONCLUSIONS: The safety of SG may be compromised by nonmodifiable factors such as age >65, patient comorbidities (DM2, hypertension), and prior treatment with anticoagulants, as well as by modifiable factors such as smoking, bougie size <40 F, distance to the pylorus <4 cm, and the surgeon's experience (<50-100 cases).

The Effects of Bariatric Surgery-Induced Weight Loss on Adipose Tissue in Morbidly Obese Women Depends on the Initial Metabolic Status.

BACKGROUND: Adipose tissue (AT) dysfunction in obesity is commonly linked to insulin resistance and promotes the development of metabolic disease. Bariatric surgery (BS) represents an effective strategy to reduce weight and to improve metabolic health in morbidly obese subjects. However, the mechanisms and pathways that are modified in AT in response to BS are not fully understood, and few information is still available as to whether these may vary depending on the metabolic status of obese subjects. METHODS: Abdominal subcutaneous adipose tissue (SAT) samples were obtained from morbidly obese women (n = 18) before and 13.3 ± 0.37 months after BS. Obese women were stratified into two groups: normoglycemic (NG; Glu < 100 mg/dl, HbA1c <5.7 %) or insulin resistant (IR; Glu 100-126 mg/dl, HbA1c 5.7-6.4 %) (n = 9/group). A multi-comparative proteomic analysis was employed to identify differentially regulated SAT proteins by BS and/or the degree of insulin sensitivity. Serum levels of metabolic, inflammatory, and anti-oxidant markers were also analyzed. RESULTS: Before surgery, NG and IR subjects exhibited differences in AT proteins related to inflammation, metabolic processes, the cytoskeleton, and mitochondria. BS caused comparable weight reductions and improved glucose homeostasis in both groups. However, BS caused dissimilar changes in metabolic enzymes, inflammatory markers, cytoskeletal components, mitochondrial proteins, and angiogenesis regulators in NG and IR women. CONCLUSIONS: BS evokes significant molecular rearrangements indicative of improved AT function in morbidly obese women at either low or high metabolic risk, though selective adaptive changes in key cellular processes occur depending on the initial individual's metabolic status.

New laparoscopic assisted percutaneous gastrostomy. Description and comparison with others gastrostomy types.

INTRODUCTION: Gastrostomy feeding tube insertion has become a common procedure as it enables patients who require long term enteral feeding. Conventional surgical gastrostomies were the only way of gaining enteral access in patients in which it is not possible to pass an endoscope or a nasogastric tube required for endoscopic or radiological gastrostomies, and in patients in which certain anatomical abnormalities contraindicate performing these techniques. As conventional surgical gastrostomies are associated with high morbidity, especially gastric leakage around the tube, percutaneous laparoscopic assisted gastrostomy (PLAG) may be a better way to gain enteral access. MATERIAL AND METHODS: Observational study of a prospective cohort of 224 patients on whom a gastrostomy was performed for nutritional support between January 2009 and October 2015 at Virgen del Rocío University Hospital in Seville. The types of gastrostomies carried out were: percutaneous endoscopic gastrostomy (PEG, n = 106), percutaneous radiological gastrostomy (PRG, n = 89), conventional surgical gastrostomy, Open Stamn or Laparoscopic Janeway (SG, n = 9) and percutaneous laparoscopic assisted gastrostomy (PLAG, n = 20), technique that we describe in detail. Short and long term complications are described. RESULTS: Many more complications were seen in the conventional gastrostomy group than in the other three groups, especially leakage of gastric content around the tube, with burning and irritation of the skin (66% compared with 2.83% in PEG and 0% in PLAG and PRG). The group with the highest proportion of patients completely free of complications was PLAG (75%), whilst in the conventional surgical gastrostomy group, no patient was completely free of complications. CONCLUSIONS: We found lower complication rate in PLAG than any other technique. We believe that PLAG could be preferred technique for patients on whom it is not possible to perform PEG or PRG, as it is safe and easy.

[SHORT BOWEL SYNDROME AND NUTRITIONAL ENTERAL]. / NUTRICIÓN ENTERAL EN SÍNDROME DE INTESTINO CORTO.

The particularity of this case is the nutritional management that has managed to avoid the use of prolonged parenteral nutrition and possible complications by placing jejunal tube at the distal end in patients with short bowel. It is a 34-year-old colecistectomizado complicated with postoperative peritonitis and dehiscence; two years he studied with small bowel obstruction, he was made de-volvulus and was complicated with two leak at different times after the second escape took place jejunostomy side double barreled shotgun level dehiscence, presented high debits by afferent loop of the terminal jejunostomy; during admission, polyurethane probe enteral feeding was inserted by the efferent loop jejunostomy. He received jejunal tube feeding laundry in the efferent loop terminal with decreased weight gain and subsequent reconstruction of intestinal transit debit proximal jejunostomy.

Lo más característico del presente caso es el manejo nutricional del paciente, que ha logrado evitar la utilización de nutrición parenteral total de forma prolongada y sus posibles complicaciones, mediante la administración de una nutrición enteral a través de una sonda yeyunal en el extremo distal de una ileostomía en un paciente con intestino corto severo. Se trata de un hombre de 34 años de edad, con antecedentes de colecistectomía complicada con peritonitis postquirúrgica y dehiscencia, que a los dos años desarrolló un cuadro de obstrucción de intestino delgado, por lo que se realizó devolvulación de intestino delgado que se complicó con dos fugas intestinales en diferentes tiempos; tras la segunda fuga se realizó yeyunostomía lateral en doble cañón de escopeta a nivel de la dehiscencia; presentó altos débitos por el asa aferente de la yeyunostomía terminal; durante el ingreso se insertó una sonda de poliuretano para alimentación enteral por asa eferente de la yeyunostomía. Recibió nutrición enteral por sonda yeyunal colada en el asa eferente con disminución del débito de yeyunostomía proximal terminal y ganancia de peso con posterior reconstrucción del tránsito intestinal.

[Bariatrica paraplegia patient and morbid obesity. New challenge in bariatric surgery]. / Paciente con paraplejia y obesidad mórbida; nuevo reto en la cirugía bariátrica.

The loss of mobility due to spinal cord injury is a risk factor for weight gain. Despite the well-documented outcomes of bariatric surgery in outpatients, little information is available about the surgery in paraplegic patients. We present two cases of patients with morbid obesity and spinal cord injury. After several attempts to lose weight conservatively, were assessed by the multidisciplinary team of our hospital and finally intervened by laparoscopic gastric bypass. After surgery have been no post-surgical complications. The patient in case 1, after two years of follow-up, a weight of 84 kg (BMI 25.08 kg/m2). Case 2, after a month of surgery has reduced weight and stopped taking antihypertensive therapy. It 's available to bariatric surgery as an important option to consider if all non-surgical interventions fail is highlighted.

La pérdida de la movilidad, como consecuencia de una lesión medular, es un factor de riesgo para el aumento de peso. A pesar de los resultados bien documentados de la cirugía bariátrica en pacientes ambulatorios, hay poca información disponible acerca de la cirugía en pacientes parapléjicos. Presentamos dos casos clínicos de pacientes con obesidad mórbida y lesión medular. Tras varios intentos para perder peso de forma conservadora, fueron valorados por el equipo multidisciplinar de nuestro hospital y finalmente se intervinieron mediante bypass gástrico por vía laparoscópica. El caso 1, tras dos años de seguimiento, presenta un peso de 84 kg (IMC 25,08 kg/m2). El caso 2, tras un mes de la cirugía ha reducido de peso y ha dejado de tomar tratamiento hipotensor. En ellos, destaca la disposición de la cirugía bariátrica como una opción a tener en cuenta si todas las intervenciones no quirúrgicas fracasan.

[Gastrocolic fistula as a complication of percutaneous feeding gastrostomy, description of three cases and review of the literature]. / Fístula gastrocólica como complicación de gastrostomía percutánea de alimentación, a propósito de tres casos y revisión de la literatura.

INTRODUCTION: Percutaneous gastrostomy, is the procedure of choice to provide enteral access in patients requiring nutritional support in this way in the long run, relegating the surgical gastrostomy. MATERIAL AND METHODS: We present three patients requiring percutaneous gastrostomy for nutritional support. In two cases was performed endoscopic gastrostomy and another one using interventional radiology. RESULTS: While performing percutaneous gastrostomy clinical incidents were not detected, but when trying the replacement of gastrostomy tubes, showed the presence of gastrocolic fistula that caused failure or turnover in one case, or abdominal pain and diarrhea in the two other cases. DISCUSSION: Despite being a safe technique, should be done a proper patient selection in order to minimize the potential complications that may occur, as gastrocolic fistula, recommending in doubtful cases test of image such CT (computerized Tomography).

Introducción: La gastrostomía percutánea es el procedimiento de elección para proporcionar acceso enteral en pacientes que requieren soporte nutricional por esta vía a largo plazo, relegando a la gastrostomía quirúrgica. Material y métodos: Presentamos tres pacientes con indicación de gastrostomía percutánea para soporte nutricional. En dos casos se realizó la gastrostomía mediante endoscopia y en otro mediante radiología intervencionista. Resultados: Durante la realización de las gastrostomías no se detectaron incidencias clínicas, pero al intentar recambio de las sondas de gastrostomía, se evidenció la presencia de fístula gastrocólica que, ocasionaba imposibilidad del recambio en un caso, o cuadro de dolor abdominal y diarrea en los otros dos casos. Discusión: Pese a ser una técnica segura, la gastrostomía percutánea debe realizarse con una correcta selección de los pacientes para minimizar posibles complicaciones que puedan acontecer, como fístula gastrocólica, recomendando en casos dudosos la realización de prueba de imagen tipo TC (tomografía computerizada).

[25 years of laparoscopic surgery in Spain]. / 25 años de cirugía laparoscópica en España.

INTRODUCTION: The introduction of laparoscopic surgery (LS) can be considered the most important advancement in our specialty in the past 25 years. Despite its advantages, implementation and consolidation has not been homogenous, especially for advanced techniques. The aim of this study was to analyse the level of development and use of laparoscopic surgery in Spain at the present time and its evolution in recent years. MATERIAL AND METHODS: During the second half of 2012 a survey was developed to evaluate different aspects of the implementation and development of LS in our country. The survey was performed using an electronic questionnaire. RESULTS: The global response rate was 16% and 103 heads of Department answered the survey. A total of 92% worked in the public system. A total of 99% perform basic laparoscopic surgery and 85,2% advanced LS. Most of the responders (79%) consider that the instruments they have available for LS are adequate and 71% consider that LS is in the right stage of development in their environment. CONCLUSIONS: Basic laparoscopic surgery has developed in our country to be considered the standard performed by most surgeons, and forms part of the basic surgical training of residents. With regards to advanced LS, although it is frequently used, there are still remaining areas of deficit, and therefore, opportunities for improvement.

Resolution of type 2 diabetes and prediabetes following laparoscopic sleeve gastrectomy: medium term results.

PURPOSE: To determine the impact of Laparoscopic Sleeve Gastrectomy (LSG) on the resolution of type 2 diabetes (T2DM) and Prediabetes (PDM) in obese patients, as well as potential improvements in other comorbidities. MATERIAL AND METHODS: Observational retrospective study. We studied all patients with T2DM (n= 36) or PDM (n= 44) who underwent LSG in our hospital between years 2009 and 2012. PDM was defined as having at least 2 values of HbA1c between 5.7 and 6.4%. Follow-up period was 1-4 years (mean 17.5 months). T2DM remission criteria were fasting plasma glucose (FPG).

Objetivos: Evaluar la efectividad de la gastroplastia tubular laparoscópica (GTL) en la resolución de la diabetes tipo 2 (DM2), de la prediabetes (PDM) y de otras comorbilidades en pacientes obesos. Material y métodos: Estudio observacional retrospectivo. Se incluyeron a los pacientes con DM2 (n= 36) o PDM (n= 44) que fueron sometidos a GTL en nuestro hospital entre 2009 y 2012. Se consideró criterio de PDM presentar HbA1c entre 5.7-6.4% en al menos dos ocasiones. Periodo de seguimiento entre 1-4 años (media 17.5 meses). Como criterio de resolución de la DM2 se consideró presentar HbA1c.

Use of hyaluronidase cream to prevent peritoneal adhesions in laparoscopic ventral hernia repair by means of intraperitoneal mesh fixation using spiral tacks.

BACKGROUND: The aim of this study was to investigate the effects of hyaluronidase gel on the prevention of post-operative peritoneal adhesions to prosthetic materials used in laparosopic ventral hernia repair. METHODS: Ten pigs were included in this study. The animals were anesthetized using Na-penthotal for induction and isofluorane for maintenance. The abdomen was opened and, using helical fasteners, four implantations were performed (squares of 4 x 4 cm). Two of the implants, placed in an upper location, were in polypropylene mesh, and two of the implants, placed in a lower area, were in polytetrafluoroethylene (PTFE-e, Dualmesh Plus Corduroy). The implants located in the right side of animals were painted with hyaluronidase gel. Two helical fasteners, painted and unpainted, were implanted in a medial location. After a five-week period the pigs were operated on again, intraperitoneal adhesion ratios and grades were determined, and the pigs later sacrificed. Specimens having abdominal wall implants were taken for histological studies. RESULTS: Intraperitoneal adhesions decreased in implants painted with hyaluronidase gel in a comparative study with implants located in the left side of animals (not painted). On the other hand the polypropylene mesh, said typically to produce intraperitoneal adhesions, produced almost no adhesion in many animals. CONCLUSIONS: Hyaluronidase gel reduces post-operative peritoneal adhesions ratio and grades including in the presence of polypropylene mesh.

[Prevention of peritoneal adhesions to intraperitoneal prostheses. An experimental study in pigs]. / Prevención de adherencias peritoneales a las prótesis intraperitoneales. Estudio experimental en cerdos.

INTRODUCTION: The aim of this study was to investigate the effect of fibrin glue and hyaluronidase gel on the prevention of postoperative peritoneal adhesions to intraperitoneal prostheses. MATERIAL AND METHOD: Twenty pigs, divided in two groups, were included. In all animals, four implants (4 x 4 cm) were placed: two polypropylene mesh implants were placed in an upper location and two polytetrafluoroethylene (PTFE) implants (Dualmesh Plus Corduroy) were placed in a lower position. Implants located in the right side of the animals were painted with fibrin glue (group A, n = 10) or with hyaluronidase gel (group B, n = 10). After 5 weeks, the animals were sacrificed and the results (number and grade of intraperitoneal adhesions, histological data on prosthesis integration, such as mesothelialization, fibroblast infiltration, vessel neoformation, etc.) were evaluated. RESULTS: Intraperitoneal adhesions decreased in implants painted with fibrin glue and hyaluronidase gel compared with untreated implants. When right-sided adhesions formed, they were looser and in many animals, the implants were completely peritonized. Integration of the prostheses was not affected by either fibrin glue or hyaluronidase gel. CONCLUSIONS: Adhesion formation can be reduced after abdominal surgery. The reduction achieved in this study was greater in the quantity than in the consistency of the adhesions. The results with hyaluronidase gel were moderately superior to those obtained with fibrin glue. Hyaluronidase gel has the advantage of being inexpensive.