Barrett's esophagus and esophageal cancer after sleeve gastrectomy. Myth or reality?

Sleeve gastrectomy has become the most performed bariatric surgery technique in the world. This bariatric technique has been related to the appearance of gastroesophageal reflux and recently with de novo Barrett's esophagus. It is not clear that this leads to an increased incidence of esophageal adenocarcinoma. In this review we analyze the current scientific literature to try to answer the true incidence of Barrett's esophagus and adenocarcinoma after sleeve gastrectomy, and whether these data should make us change the indications for this technique.

Consequencies of therapeutic decision-making based on FAST results in trauma patients with pelvic fracture.

INTRODUCTION: FAST is essential to decide whether trauma patients need laparotomy, but it has a notable decrease in accuracy in patients with pelvic fracture. Our objective is to analyze the consequences of therapeutic decision-making based on the FAST results in trauma patients with pelvic fracture. METHODS: Descriptive study that includes trauma patients older than 16 with a pelvic fracture admitted to the critical care area or who died. The FAST result was compared with a true positive or negative value according to the results of laparotomy or abdominal CT. We recorded diagnosis and treatment of each injury and resolution of the case, detailing the cause of death, among all variables. RESULTS: Over the 13-year period, we included 263 trauma patients with pelvic fracture, with a mean ISS of 31 and mortality of 19%. FAST had a sensitivity of 65.2%, specificity of 69%, false negative rate of 34.8% and false positive rate of 30.9%. Hemodynamically unstable patients died twice as many stable patients (27% vs 14%, P < .05). Patients with positive FAST died more than negative FAST (43% vs 26%); and 4 out of 10 hemodynamically unstable patients who underwent non-therapeutic laparotomy after presenting a false positive FAST died from hypovolemic shock. The mortality rate fell from 60% to 20% when preperitoneal packing was performed before angio-embolization of the pelvis. CONCLUSION: FAST has low accuracy in polytraumatized patients with pelvic fracture. Patients with false positive FAST have higher mortality, which can be reduced notably by applying preperitoneal packing.

Diagnostic tests for preoperative staging of esophagogastric junction tumors: performance and evidence-based recomendations. / Pruebas diagnósticas empleadas en la estadificación preoperatoria del cáncer de la unión esofagogástrica: rendimiento y recomendaciones basadas en la evidencia.

Preoperative clinical staging is critical to select those patients whose disease is localized and may benefit from surgery with curative intent. Ideally, such staging should predict tumor invasion, lymphatic involvement and distant metastases. With the cTNM, we are able to select patients who could benefit from endoscopic resection, radical surgery or less radical treatment in patients with distant metastasis. The initial diagnosis of adenocarcinomas of the esophagogastric junction requires endoscopy with biopsies. For clinical staging, thoracoabdominal-pelvic CT scan, endoscopic ultrasound and PET or PET/CT are used. Other useful explorations are: barium swallow, endoscopic mucosal resection or endoscopic submucosal dissection (for assessment in initial stages) and staging laparoscopy. Once the resectability of the tumor has been established, the operability of the tumor should be assessed according to the patient's condition.

Acute mesenteric ischemia: Utility of endovascular techniques.

INTRODUCTION: Acute mesenteric ischemia (AMI) has a high mortality. Early diagnosis and treatment are very important. In our institution there is a therapeutic protocol that includes endovascular techniques (ET) in patients with AMI without peritoneal irritation at diagnosis. The aim of this study was to evaluate the use of ET in conjunction with conventional surgery in the management of potentially reversible IMA diagnosed by computed tomography (CT-angiography). METHODS: Observational, descriptive and retrospective study that evaluated the use of ET in patients with AMI (arterial origin) in 2 periods (before and after the application of a protocol that includes ET), between 2009-2013. All patients were diagnosed by a CT-angiography, as the diagnostic technique of choice, because of the clinical and analytical suspicion. RESULTS: Our series included 73 patients with IMA diagnosed by CT-angiography (45: 2009-2011; 28: 2012-2013). Leukocytosis was common (82%), high lactate levels are less frequent (47% vs. 53%). There were 49 patients with IMA without peritoneal irritation. In 51% bowel resection surgery was performed (44% survival); 18%: revascularization by ET (survival 67%); 31%: palliative treatment (0% survival). 33% of patients undergoing first-line RVI needed a surgical rescue (bowel resection). The overall mortality was 67% (2009-2011) vs. 62% (2012-2013). CONCLUSIONS: Since the protocol application, there is a higher indication of ET in patients with AMI without peritoneal irritation, showing a decreased mortality. With ET application, there is a higher survival in these patients. In our experience, the use of ET in cases of AMI without peritoneal irritation at diagnosis, may increase survival.

Surgical electronic logbook: A step forward.

INTRODUCTION: The surgical electronic logbook (surgical e-logbook) aims to: simplify registration of the training activities of surgical residents, and to obtain reliable and detailed reports about these activities for resident evaluation. METHODS: The surgical e-logbook is a unique and shared database. Residents prospectively record their activities in 3 areas: surgical, scientific and teaching. We can access activity reports that are constantly updated. RESULTS: Study period using the surgical e-logbook: Between June 2011 and May 2013. Number of surgeries reported: 4,255. Number of surgical procedures reported: 11,907. Number of surgeries per resident per year reported: 250. Number of surgical procedures per resident per year reported: 700. Surgical activity as a primary surgeon during the first year of residency is primarily in emergency surgery (68,01%) and by laparotomy (97,73%), while during the fifth year of residency 51,27% is performed in elective surgery and laparoscopy is used in 23,10% of cases. During this period, residents participated in a total of 11 scientific publications, 75 conference presentations and 69 continuing education activities. CONCLUSIONS: The surgical e-logbook is a useful tool that simplifies the recording and analysis of data about surgical and scientific activities of the residents. It is a step forward in the evaluation of the training of surgical residents, however, is only an intermediate step towards the development of a larger Spanish registry.

[Validation of abdominal wound dehiscence's risk model]. / Validación de un modelo de riesgo de evisceración.

INTRODUCTION: The aim of this study is to determine the usefulness of the risk model developed by van Ramshorst et al., and a modification of the same, to predict the abdominal wound dehiscence's risk in patients who underwent midline laparotomy incisions. MATERIALS AND METHODS: Observational longitudinal retrospective study. SAMPLE: Patients who underwent midline laparotomy incisions in the General and Digestive Surgery Department of the Sabadell's Hospital-Parc Taulí's Health and University Corporation-Barcelona, between January 1, 2010 and June 30, 2010. Dependent variable: Abdominal wound dehiscence. INDEPENDENT VARIABLES: Global risk score, preoperative risk score (postoperative variables were excluded), global and preoperative probabilities of developing abdominal wound dehiscence. SAMPLE: 176 patients. Patients with abdominal wound dehiscence: 15 (8.5%). The global risk score of abdominal wound dehiscence group (mean: 4.97; IC 95%: 4.15-5.79) was better than the global risk score of No abdominal wound dehiscence group (mean: 3.41; IC 95%: 3.20-3.62). This difference is statistically significant (P<.001). The preoperative risk score of abdominal wound dehiscence group (mean: 3.27; IC 95%: 2.69-3.84) was better than the preoperative risk score of No abdominal wound dehiscence group (mean: 2.77; IC 95%: 2.64-2.89), also a statistically significant difference (P<.05). The global risk score (area under the ROC curve: 0.79) has better accuracy than the preoperative risk score (area under the ROC curve: 0.64). CONCLUSION: The risk model developed by van Ramshorst et al. to predict the abdominal wound dehiscence's risk in the preoperative phase has a limited usefulness. Additional refinements in the preoperative risk score are needed to improve its accuracy.

[Measurement of lactic acid in multiple injury patients and its usefulness as a predictor of multiorgan failure and mortality]. / Medición del ácido láctico en pacientes politraumatizados y su utilidad como factor predictor de mortalidad y fallo multiorgánico.

INTRODUCTION: The use of lactic acid as marker of occult hyperfusion and its relationship with multiorgan failure (MOF) and/or mortality is a subject of debate. MATERIAL AND METHOD: A prospective study was conducted on multiple injury patients over 16 years of age in critical care areas. The lactic acid was measured at the beginning and at 24 hours of the trauma and associating it with the patient morbidity and mortality. RESULTS: A total of 342 patients, with a mean injury severity score of 24.1, were included. The patients who survived had an initial, and 24 hours after the trauma, lactic acid of 27.8 mg/dl and 17.9 mg/dl, respectively, (normal values less than 22 mg/dl), increasing to 36.5mg/dl and 40.2mg/dl, respectively, in those who died. There were no differences between the initial lactic acid in patients with and without MOF, being increased at 24 hours in those who had MOF (17.8 vs 26.7). The patients with a lactic acid that got worse or remained abnormal at 24 hours had a higher mortality than those in which it remained the same or improved (25% - 17.1% vs 6.3% - 0.8%), with the percentage of patients with MOF also increasing (40.6% - 32.8% vs 14.9% - 11.1%). In haemodynamically stable patients, there was also a higher mortality when the lactic acid got worse or remained abnormal in the first 24 hours (23.8% - 19.2% vs 8.8% - 0%), as well as a higher percentage of MOF (38.1% - 26.9% vs 10.9% - 7.6%). CONCLUSIONS: The lactic acid results in the first 24 hours of the multiple injury patient are associated with mortality and MOF, even when the patient is haemodynamically stable.

Gastrointestinal stromal tumors: experience in 49 patients.

INTRODUCTION: Gastrointestinal stromal tumours (GIST) are mesenchymal tumours of the digestive tract originated in the interstitial cells of Cajal. They express the tyrosine kinase c-kit (CD117) activity receptor. Mutations in this receptor cause neoplastic development. Curative treatment continues to be radical resection of the tumour and is resistant to commonly employed chemotherapy regimens. Imatinib mesilate is a drug that inhibits c-kit activity expressed by GIST and its activity in these tumours has been demonstrated. MATERIAL AND METHODS: Retrospective study of all cases of leiomyoma, leiomyosarcoma, schwannoma, and stromal or mesenchymal tumors from 1989 to July 2004. C-kit and CD34 proteins were detected at immunohistochemical study in addition to the usual markers for mesenchymal tumours. RESULTS: 49 GISTs were diagnosed, 26 males and 23 females (mean age 64.1). Symptoms were digestive tract bleeding (n = 13), abdominal pain (n = 13), intestinal occlusion (n = 4) and others. The lesion was located in small bowel (n = 22), stomach (n = 19), rectum (n = 3), peritoneum (n = 2), esophagus (n = 1), omentum (n = 1), and retroperitoneum (n = 1). Forty-three of the 49 patients underwent surgery; radical resection was performed in 37 (75.5%) and palliative surgery in the other six (16.2%). Two of the patients that did not undergo surgery received chemotherapy. At the time of study, 28 (57.14%) patients remained alive, 23 (46.9%) of whom were disease- free and five (10.2%) were not. Nineteen (38.7%) patients died. CONCLUSIONS: The results of our series are similar to the others published. Before the year 2001, surgery was the only successful option for the GIST. Surgical resection continues being the best treatment to definitively cure this disease. Imatinib is used to treat not only resectable tumours, but even to allow the possibility to make a subsequent rescue surgery. On the other hand, Imatinib is used in the treatment of the metastatic disease.