Lessons Learned in Elective Surgeries After 6 Pandemic Waves of SARS-CoV-2. A Single European Center Experience.

BACKGROUND: The reported high surgical morbidity and mortality in patients with SARS-CoV-2 prompted preoperative screening and modification of surgical protocols. Although vaccination and treatment of COVID-19 have resulted in lower hospitalization rates and infection severity, publications on postoperative results have not been updated. The aim of the study was to analyze the outcomes of patients undergoing surgery in two periods with high incidence of SARS-CoV-2 infection, before and after vaccination. MATERIALS AND METHODS: This is a prospective cohort study of patients undergoing surgery in two periods: March-June 2020 (Group2020) and December 2021-February 2022 (Group2022) (after massive vaccination). RESULTS: In total, 618 patients who underwent surgery were included in the analysis (Group2020: 343 vs. Group2022: 275). Significantly more oncological procedures were performed in Group2020, and there were no differences in postoperative complications. Nosocomial SARS-CoV-2 infection occurred in 4 patients in Group2020 and 1 patient in Group2022. In Group 2022, 70 patients (25.4%) had COVID-19 prior to surgery, and 68 (97.1%) were vaccinated. Comparative analysis between patients with past COVID-19 and those without showed no difference in postoperative morbidity and mortality. According to the time elapsed between SARS-CoV-2 infection and surgery (≤ 7 or > 7 weeks), comparative analysis showed no significant differences. CONCLUSION: The establishment of preoperative screening protocols for SARS-CoV-2 infection results in a low incidence of nosocomial infection and optimal postoperative outcomes. Preoperative SARS-CoV-2 infection in vaccinated patients was not associated with increased postoperative complications, even in shorter periods after infection. In surgical patients, individualized preoperative evaluation after SARS-CoV-2 infection may be more important than strict time limitation.

Mixed Meal Tolerance Test Versus Continuous Glucose Monitoring for an Effective Diagnosis of Persistent Post-Bariatric Hypoglycemia.

Gastric bypass determines an increase in incretin secretion and glucose excursions throughout the day and may sometimes entail the development of severe post-bariatric hypoglycemia (PBH). However, there is no consensus on the gold standard method for its diagnosis. In this study, we evaluated the usefulness of a mixed meal tolerance test (MMTT) and continuous glucose monitoring (CGM) for the diagnosis of PBH, defined as glucose levels <54 mg/dL (3.0 mmol/L). We found that hypoglycemia occurred in 60% of patients after the MMTT and in 75% during CGM, and it was predominantly asymptomatic. The MMTT confirmed the diagnosis of PBH in 88.9%of patients in whom surgery had been performed more than three years ago, in comparison to 36.4% in cases with a shorter postsurgical duration. CGM diagnosed nocturnal asymptomatic hypoglycemia in 70% of patients, and daytime postprandial hypoglycemia in 25% of cases. The mean duration of asymptomatic hypoglycemia was more than 30 min a day. Patients with ≥2% of their CGM readings with hypoglycemia exhibited a higher degree of glucose variability than those with <1% of the time in hypoglycemia. Our results show that the MMTT may be a useful dynamic test to confirm the occurrence of hypoglycemia in a large number of patients with persistent and recurrent PBH during long-term follow-up after gastric bypass. CGM, on its part, helps identify hypoglycemia in the real-world setting, especially nocturnal asymptomatic hypoglycemia, bringing to light that PBH is not always postprandial.

Effect of Obesity and Roux-En-Y Gastric Surgery on Omeprazole Pharmacokinetics.

INTRODUCTION: The prevalence of obesity is increasing globally. The principal aim was to evaluate whether gastric bypass surgery modifies the bioavailability and pharmacokinetic (PK) parameters of omeprazole. METHODS: Controlled, open-label, bioavailability clinical trial in patients undergoing Roux-en-Y gastric bypass (RYGB). Healthy patients with obesity (body mass index >35) were included and assessed for omeprazole PKs before and after RYGB (1 and 6 months). PK sampling was done at baseline and several times up to 12 h after drug dosing. Pre- and post-surgery parameters were compared using paired ANOVA or Wilcoxon tests, and control versus cases using ANOVA or Mann-Whitney tests. Given the post-surgery change in body weight, parameters were corrected by dose/body weight. RESULTS: Fourteen case and 24 control subjects were recruited; 92% were women (N = 35/38). In patients who underwent RYGB, maximum plasma concentration (Cmax) was significantly reduced at 1 and 6 months after surgery compared with presurgery values (p = 0.001). Regarding the AUC, the values are lower at 1 and 6 months after surgery than at baseline (p < 0.001). The drug clearance was also increased in the first month after surgery. No differences were found between patients 6 months after surgery and controls. Cmax and AUC corrected by dose/body weight were significantly different between the baseline surgery subjects and controls. Discusion/Conclusions: Omeprazole bioavailability is reduced in patients with obesity at 1 and 6 months after RYGB. However, omeprazole PK parameters 6 months after RYGB are similar to control subjects, and thus no dose correction is required after RYGB for a given indication.

Conversion from Roux-En-Y Gastric Bypass to Single Anastomosis Duodenoileal Bypass (SADI-S) for Weight Regain.

BACKGROUND: Revisional bariatric surgery presents a challenge for bariatric surgeons. This procedure can be considered for patients with inadequate weight loss or weight regain after an initial satisfactory response following bariatric surgery. However, the surgical management of weight regain following RYGB remains controversial. We present a case of successful weight gain management after a single anastomosis duodenoileal bypass with sleeve gastrectomy (SADIS) as a revisional procedure for patients with weight regain after RYGB. METHODS: A 23-year-old female with a body mass index (BMI) of 52 kg/m2 and no comorbidities underwent RYGB. Postoperatively, she reached an excess weight loss of 75% of her initial body weight, with a BMI of 32 kg/m2. Eight years after her RYGB, she started regaining weight, reaching a BMI of 47 kg/m2. The surgical team decided to perform a revisional surgery, a conversion of RYGB to SADIS. RESULTS: There were no intraoperative complications. An upper gastrointestinal series was obtained on the third postoperative day which resulted normal and oral feedings were resumed. The patient was then discharged on fifth postoperative day. There were no complications within the first 30 postoperative days. CONCLUSIONS: We attach a video that illustrates the management and technique used to deal with the weight regain after primary bariatric surgery RYGB. We consider that in patients with super morbid obesity refractory to RYGB, conversion to SADIS is an excellent alternative due to its safety and feasibility.

Obesity and telomere status in the prognosis of patients with colorectal cancer submitted to curative intention surgical treatment.

The risk of colorectal cancer (CRC) development has been associated with telomere dysfunction and obesity. However, clinical relevance of these parameters in CRC prognosis is not clear. Therefore, the aim of the present study was to evaluate the impact of obesity and telomere status in the prognosis of patients affected by CRC and submitted to curative surgical treatment. According to published data, this is the first work in which obesity and telomere status are jointly considered in relation to CRC prognosis. A prospective study including 162 patients with CRC submitted to curative surgical treatment was performed. Subjects were classified according to their BMI. Telomere status was established through telomere length and telomerase activity evaluation. Statistical analyses were performed using the SPSS software package version 22. Telomere shortening was inversely associated with BMI in patients with CRC. Notably, among patients with CRC, subjects with obesity exhibited less shortening of tumor telomeres than non-obese patients (P=0.047). Patients with shorter telomeres, both in the tumor (median telomere length <6.5 kb) and their non-tumor paired tissues (median telomere length <7.1 kb), had the best clinical evolution, regardless of the Dukes' stage of cancers (P=0.025, for tumor samples; P=0.003, for non-tumor samples). Additionally, subjects with a BMI >31.85 kg/m2 showed the worse clinical outcomes compared with subjects with other BMI values. Interestingly, the impact of BMI showed sex dependence, since only the group of men displayed significant differences in CRC prognosis in relation to obesity status (P=0.037). From the results of the present study, based on a multivariate prediction model to establish prognosis, it was concluded that telomere length is a useful biomarker to predict prognosis in patients with CRC. Regardless of BMI values, the improved clinical evolution was associated with shorter telomeres. The impact of BMI seems to be associated with other factors, such as sex.

Evaluation of Myocardial Function Following SADI-S.

PURPOSE: The aim of this study was to compare myocardial mechanics using global longitudinal strain (GLS) before and after single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). MATERIALS AND METHODS: A total of 21 obese patients undergoing SADI-S were prospectively included. Transthoracic echocardiography was performed before and after the procedure, and left ventricle (LV) and right ventricle (RV) strain was assessed by two-dimensional speckle-tracking imaging (2DST). RESULTS: Mean time between pre-procedural and post-procedural echocardiograms was 9.2 ± 3.3 months. Postoperatively, %total weight loss (%TWL) was 33.0 ± 1.7 and % excess weight loss (%EWL) was 75.5 ± 3.6. Body mass index (BMI) significantly decreased after surgery (45.6 ± 1.2 vs 29.6 ± 1.0; p < 0.001). Postoperatively, LV GLS experienced a significant improvement (-19.8% ± 0.5 vs -22.2% ± 0.4; p < 0.001). Regarding other relevant functional parameters, RV free-wall strain was equally recovered (-19.1% ± 0.7 vs -21.0% ± 0.8; p 0.047). CONCLUSIONS: This study demonstrates important and favourable changes in cardiac deformation parameters after performing SADI-S. Malabsorptive bariatric techniques such as SADI-S induce significant weight loss, leading to an improvement in subclinical myocardial function in patients with obesity.

Schwannoma: Differential diagnosis of a subepithelial gastric lesion. Two case report.

The pre-operative differential diagnosis of gastric subepithelial lesions is complex. We can find pathologies with a very different behavior. Some of them, like gastrointestinal (GI) stromal tumors, can present a malignant behavior, and others like schwannomas are practically benign. Schwannomas of the GI tract originate from the Schwann cells of the Auerbach plexus and their most frequent location is the stomach. The definitive diagnosis is made by immunohistochemical analysis of the surgical specimen and its resection is curative. We report two cases of gastric subepithelial lesions with a definitive diagnosis of schwannoma.

El diagnóstico diferencial preoperatorio de las lesiones subepiteliales gástricas es complejo. Podemos encontrar patologías con un comportamiento muy diferente. Algunas de ellas, como los GIST (gastrointestinal stromal tumours), pueden presentar un comportamiento maligno, y otras, como los schwannomas, son prácticamente benignas. Los schwannomas del tracto gastrointestinal se originan de las células de Schwann del plexo de Auerbach y su localización más frecuente es el estómago. El diagnóstico definitivo se realiza mediante el análisis inmunohistoquímico de la pieza quirúrgica, y su resección es curativa. Reportamos dos casos de lesiones subepiteliales gástricas con diagnóstico definitivo de schwannoma.

Thyroid metastases from colorectal cancer 14 years later: A case report and literature review.

Metastases to the thyroid gland are unusual, especially from a colorectal cancer. We present the case of an 85-year-old female with a history of colon cancer in 2004 treated with surgery, who 14 years later develop dysphonia and dysphagia associated to an elevation of carcinoembryonic antigen. A pathologic thyroid mass was evidenced in a positron emission tomography-computed tomography. The colorectal origin of the mass was confirmed with a biopsy. The patient received surgical treatment doing the right hemithyroidectomy. This entity must be suspected in patients with oncological history and a new thyroid nodule. Surgery is a therapeutic option with either curative or palliative intent.

Las metástasis sobre el tiroides son inusuales y las de origen colorrectal son extremadamente infrecuentes. Se presenta el caso de una mujer de 85 años con antecedente de cáncer de colon intervenido en 2004 que 14 años después presenta signos clínicos de disfonía y disfagia relacionados con elevación del CEA. Tras realizarse una PET-TC se evidencia una masa tiroidea y se confirma su origen colorrectal mediante biopsia. La paciente se sometió a una hemitiroidectomía derecha. Esta entidad debe sospecharse en pacientes con antecedentes oncológicos y un nódulo tiroideo de nueva aparición. La intervención es una opción terapéutica con intención curativa y paliativa.

Long-term results of botulinum toxin type A in complex abdominal wall repair and review of the literature.

Administration of botulinum toxin (BTX) is being used in cases of complex ventral hernia for the reconstruction of the linea alba and closure of the abdominal wall. However, there are no published results regarding the long-term effects of BTX and its implication in hernia recurrence. Our purpose is to evaluate the outcomes in hernia recurrence of the administration of BTX in complex ventral hernia repair. 36 patients underwent elective surgery for complex ventral hernia and were evaluated retrospectively. The study included patients with a transverse hernia defect ≥ 100 mm and loss of domain hernias, receiving BTX injections 6 weeks prior to elective surgery. Global results and long-term recurrence were analysed. There were no complications related to BTX administration. The mean transverse hernia defect was 139.44 ± 50.98 mm, the mean abdominal cavity volume (ACV) was 10.19 ± 3.33 dm3, the mean hernia sac volume (HSV) was 1.93 ± 1.79 dm3, presenting a mean volume ratio (VR) of 20.71 ± 19.76%. Primary closure was achieved in 28 patients (77.8%), 21 of whom (75%) needed an anterior component separation technique. Recurrence rate was 11.4% at 2-years follow-up. BTX administration is a safe and feasible method for abdominal wall expansion prior to complex incisional hernia repair, achieving high rates of primary closure. Long-term follow-up shows good results in terms of recurrence in these patients.

Main prophylactic measures in bariatric endoscopy. Spanish Expert Recommendations Guideline.

Bariatric endoscopy (BE) encompasses a number of techniques -some consolidated, some under development- aiming to contribute to the management of obese patients and their associated metabolic diseases as a complement to dietary and lifestyle changes. To date different intragastric balloon models, suture systems, aspiration methods, substance injections and both gastric and duodenal malabsorptive devices have been developed, as well as endoscopic procedures for the revision of bariatric surgery. Their ongoing evolution conditions a gradual increase in the quantity and quality of scientific evidence about their effectiveness and safety. Despite this, scientific evidence remains inadequate to establish strong grades of recommendation allowing a unified perspective on prophylaxis in BE. This dearth of data conditions leads, in daily practice, to frequently extrapolate the measures that are used in bariatric surgery (BS) and/or in general therapeutic endoscopy. In this respect, this special article is intended to reach a consensus on the most common prophylactic measures we should apply in BE. The methodological design of this document was developed while attempting to comply with the following 5 phases: Phase 1: delimitation and scope of objectives, according to the GRADE Clinical Guidelines. Phase 2: setup of the Clinical Guide-developing Group: national experts, members of the Grupo Español de Endoscopia Bariátrica (GETTEMO, SEED), SEPD, and SECO, selecting 2 authors for each section. Phase 3: clinical question form (PICO): patients, intervention, comparison, outcomes. Phase 4: literature assessment and synthesis. Search for evidence and elaboration of recommendations. Based on the Oxford Centre for Evidence-Based Medicine classification, most evidence in this article will correspond to level 5 (expert opinions without explicit critical appraisal) and grade of recommendation C (favorable yet inconclusive recommendation) or D (inconclusive or inconsistent studies). Phase 5: External review by experts. We hope that these basic preventive measures will be of interest for daily practice, and may help prevent medical and/or legal conflicts for the benefit of patients, physicians, and BE in general.

Effect of Roux-en-Y gastric surgery on ciprofloxacin pharmacokinetics: an obvious effect?

PURPOSE: To evaluate pharmacokinetic parameters of ciprofloxacin in patients undergoing Roux-en-Y gastric surgery (RYGS). METHODS: Controlled, single-dose, open-label study in patients undergoing RYGS. Healthy overweight/obese patients 18-60 years old were included. The assessment was performed once in control patients and three times in case patients (before surgery and 1 and 6 months after surgery). In each visit, the subjects received a single oral dose of ciprofloxacin 500 mg. Venous blood samples were obtained at baseline and 0.5, 1, 1.25, 1.5, 1.75, 2, 2.5, 3, 4, 8 and 14 h after ciprofloxacin intake. Pre- and post-surgery variables were compared using paired ANOVA or the Wilcoxon tests and control vs cases using ANOVA or Mann Whitney. Given the post-surgery change in body weight, the parameters were corrected by dose (mg)/body weight (kg). The analysis was performed using SPSS. RESULTS: Ciprofloxacin Cmax was significantly reduced 1 month after surgery (1840.9 ± 485.2 vs 1589.6 ± 321.8 ng/ml; p = 0.032) but not 6 months after. Cmax on the sixth month was lower than Cmax in control group (2160.4 ± 408.6 vs 1589.6 ± 321.8 ng/ml; p < 0.001). After correcting by the dose (mg)/patient's body weight, both Cmax and AUClast showed significant decrease 1 and 6 months after surgery: Cmax, 289.1 ± 65.3 and 263.5 ± 52.1 (ng/ml)/(dose (mg)/weight (kg)) respectively vs 429.3 ± 127.6 (ng/ml)/(dose (mg)/weight (kg)) at baseline; AUC, 1340.6 ± 243.0 and 1299.2 ± 415.4 (h × ng/ml)/(dose (mg)/weight (kg)) respectively vs 1896.7 ± 396.8 (h × ng/ml)/(dose (mg)/weight (kg)) at baseline. Cmax 1 month post-surgery showed lower values than the control group (375.4 ± 77.4 vs 263.5 ± 52.1 ng/ml; p < 0.001). CONCLUSION: Ciprofloxacin absorption is impaired 1 month and 6 months after RYGS. The effect on Cmax and AUClast faded on the sixth month due to weight loss. It is no necessary to modify the doses of ciprofloxacin in these patients.

Expression analysis of a cholecystokinin system in human and rat white adipose tissue.

AIM: Cholecystokinin (CCK) participates in the storage of dietary triglycerides in white adipose tissue (WAT). Our goal was to characterize, both in subcutaneous (Sc-WAT) and visceral WAT (Vis-WAT), the functional expression of the two known CCK receptors, CCK-1 (CCK-1R) and CCK-2 (CCK-2R), as well as of CCK. MAIN METHODS: Gene and protein expression was assessed in different cell types of rat and human WAT by means of RT-PCR and western-blot, respectively. The functionality of CCK-Rs was tested by quantifying protein kinase B (Akt) phosphorylation after treatment of pre-adipocytes with the bioactive fragment of CCK, CCK-8. The CCK receptor subtype involved in Akt phosphorylation was investigated by using selective CCK-1R (SR-27,897) and CCK-2R antagonists (L-365,260). KEY FINDINGS: In rats, CCK-1R (Cckar) and CCK-2R (Cckbr) gene expression was detected in the two types of WAT analyzed as well as in isolated adipocytes, mesenchymal stem cells and pre-adipocytes. CCK-1R and CCK-2R proteins were identified in adipocytes and, to a minor extent, in pre-adipocytes. In addition, CCK-2R were detected in subcutaneous mesenchymal stem cells. Gene expression of the CCK precursor preproCCK as well as CCK immunoreactivity were also found in Sc-WAT and Vis-WAT. In human WAT, CCK gene expression as well as CCK-2Rs and CCK were also identified. CCK-8 evoked Akt phosphorylation in rat pre-adipocytes, and this effect was antagonized by SR-27,897 and L-365,260. SIGNIFICANCE: Our data show that both human and rat WAT express a complete CCK system, and suggest that CCK may have an autocrine/paracrine role in regulating adipose tissue biology.

Live surgery courses: retrospective safety analysis after 11 editions.

INTRODUCTION: Live surgery is a topic of interest at every meeting or course in the field of surgery. The potential of laparoscopy for live broadcasting makes it an excellent tool in continuing medical education. Surgeons who participate in live surgeries are usually experienced, but several conditions may influence the results and safety of a procedure. OBJECTIVES: To analyze safety and outcomes in a series of patients who underwent surgery in the last 10 years in a live surgery course at our institution. SETTING: University public hospital in Spain. METHODS: Retrospective review of patients who underwent surgery during these courses from 2006 to 2016. Morbidity, mortality, and long-term results were analyzed. RESULTS: Of 107 patients, 74 (68.5%) were women, and 38 (35.2%) had revision surgery. Five had surgery during previous editions. The most performed procedures were Roux-en-Y gastric bypass (38.9%), sleeve gastrectomy (16.7%), and duodenal switch (14%). Ten cases were endoscopic procedures. Morbidity was 13% (14 cases), and 6 required early postoperative revision (5.6%). Most of the complications were Clavien types III and I. Bleeding was the most common (72.4%). There was no anastomotic leak, but 1 duodenal stump leak occurred. During follow-up, 6 patients had a surgical complication and 5 required revision surgery. There was no mortality. DISCUSSION: We found higher morbidity and reoperation rates. The conversion rate in long-term follow-up was higher. Despite the educational benefits, we should take into consideration the higher risk to our patients for future editions.

Squamous Cell Carcinoma of the Peristomal Skin of a Gastrostomy: Case Study.

BACKGROUND: Primary skin tumors that develop at enteral feeding stomas are extremely rare. Ongoing surveillance of these stomas, including the peristomal skin, is essential to early diagnosis and treatment of these tumors. CASE: A 73-year-old man with an esophageal chemical burn caused by swallowing sodium hypochlorite (bleach) approximately 50 years earlier that was initially managed with esophageal exclusion and placement of a gastrostomy device for enteral feeding presented with an exophytic and painful mass of the skin adjacent to his gastrostomy site. The pathologic report confirmed differentiated squamous cell skin carcinoma. CONCLUSION: Skin tumors arising from chronic wounds or ulcers of the skin surrounding a gastrostomy device are rare but should be considered if hypergranulation tissue or a peristomal lesion appears to be nonhealing. WOC nurses are frequently consulted for care of granulomas, and close monitoring is essential for avoiding this potentially fatal complication.

Long-Term Food Tolerance After Bariatric Surgery: Comparison of Three Different Surgical Techniques.

BACKGROUND: Food tolerance has been related to quality of life after bariatric surgery. However, long-term results about this issue are quite limited. The aim of this study was to evaluate the long-term food tolerance in obese patients submitted to surgery, comparing the results between gastric bypass (GBP), long alimentary modified biliopancreatic diversion (MBPD), and long alimentary modified duodenal switch (MDS). METHODS: A cross-sectional analytic study was performed. Food tolerance was studied with a questionnaire based on subjective alimentary satisfaction, tolerance to different foods, and frequency of vomiting and regurgitation. A food tolerance score was obtained (1 point being the worst possible tolerance and 27 points being a perfect one). Information was obtained with a telephone interview. RESULTS: One hundred ninety-six patients submitted to bariatric surgery were included. Ninety-nine patients were submitted to GBP, 54 to MBPD, and 43 to MDS. One hundred and sixty-one patients (82.1%) were not lost during a mean follow-up time of 87.9 months. Mean food tolerance score was 24.2. Tolerance satisfaction was good or excellent in 73.3% of the patients. Red meat was the worst tolerated food, but nearly 80% of the patients could tolerate it without any problem. Mean food tolerance score was 24.6, 24.0, and 23.7 for GBP, MBPD, and MDS, respectively. There were no significant differences between these procedures in food tolerance score, alimentary satisfaction, or frequency of vomiting. CONCLUSIONS: Long-term food tolerance after bariatric surgery is good. No differences between GBP, MBPD, and MDS were found.

Initial Approach to Childhood Obesity in Spain. A Multisociety Expert Panel Assessment.

PURPOSE: In recent years, the incidence of childhood obesity in Europe, and Spain in particular, has increased dramatically. Bariatric surgery could play a major role in treating of adolescents with severe obesity. However, no specific guidelines for bariatric surgery currently exist in Spain. METHODS: The Board of the Spanish Society for Obesity Surgery and Metabolic Diseases (SECO) proposed a study of childhood obesity by using the Delphi method. This prospective study involved 60 experts from nine national societies. Each society leader recruited experts from their society in obesity-related fields. Two online questionnaires were taken, and consensus on guidelines for various obesity treatments was reached according to the percentage of answers in favor or against inclusion of a given guideline. Based on these results, preoperative, surgical management and follow-up of childhood obesity management among others were analyzed. RESULTS: The survey results indicated significant concern among all societies regarding obesity. There was strong consensus with regard to adolescents and obesity, medical treatment, dietary recommendations, environmental and social factors, and goals for adolescents with obesity. Consensus on the use of intragastric balloons and other techniques was not reached. However, biliopancreatic diversion was rejected as a primary treatment, and mandatory psychological/psychiatric assessment was agreed upon. Inclusion criteria accepted were similar to those for adults with the exception of surgery in those with a body mass index <40. CONCLUSIONS: Spanish obesity-related societies are aware of the societal problem of childhood obesity. Multisociety development of national approaches may arise from consensus-building studies among specialists.