Robotic transversus abdominis release using HUGO RAS system: our initial experience.

BACKGROUND: Transversus abdominis release (TAR) is an effective technique for treating large midline and off-midline hernias. Recent studies have demonstrated that robotic TAR (rTAR) is technically feasible and associated with improved outcomes compared to open surgery. There is no published experience to date describing abdominal wall reconstruction using the novel robotic platform HUGO RAS System (Medtronic®). METHODS: All consecutive patients who underwent a rTAR in our institution were included. Three of the four arm carts of the HUGO RAS System were used at any given time. Each arm configuration was defined by our team in conjunction with Medtronic® personnel. rTAR was performed as previously described. Upon completion of the TAR on one side, a redocking process with different, mirrored arms angles was performed to continue with the contralateral TAR. Operative variables and early morbidity were recorded. RESULTS: Ten patients were included in this study. The median BMI was 31 (21-40.6) kg/m2. The median height was 1.6 m (1.5-1.89 m). A trend of decreased operative time, console time, and redocking time was seen in these consecutive cases. No intraoperative events nor postoperative morbidity was reported. The median length of stay was 3 (1-6) days. CONCLUSION: Robotic TAR utilizing the HUGO RAS system is a feasible and safe procedure. The adoption of this procedure on this novel platform for the treatment of complex abdominal wall hernias has been successful for our team.

[Barrett's Esophagus: Update on the Diagnosis and Treatment. Review]. / Esófago de Barrett: Actualización en el diagnóstico y tratamiento.

Barrett's esophagus (BE) is the condition in which a metaplastic columnar mucosa predisposed to neoplasia replaces the squamous mucosa of the distal esophagus. The current guidelines recommends that diagnosis requires the finding of intestinal metaplasia (IM) with goblet cells of at least 1 cm in length. BE affects approximately 1% of the general population and up to 14% of patients with gastroesophageal reflux disease (GERD). BE is a precursor of esophageal adenocarcinoma (EAC), which has increased in western countries. The main risk factors described for EAC associated with BE are male sex, age > 50 years, central obesity and tobacco use. Annual risk of EAC in patients with BE without dysplasia, low grade (LGD) and high-grade dysplasia is 0,1-0,3%, 0,5% y 5-8%, respectively. Treatment of non-dysplastic BE consists mainly of a healthy lifestyle change, chemoprevention with proton pump inhibitors and surveillance endoscopy every 3 to 5 years. It is recommended that from the presence of LGD patients are referred to an expert center for confirmation of the diagnosis, stage and thus define their management. In patients with BE and dysplasia or early-stage cancer, endoscopic therapy with resection and ablation is successful in about 90% of the patients. The main adverse event is esophageal stricture, which is managed endoscopically.

Enhanced-view totally extraperitoneal (eTEP) approach for the treatment of abdominal wall hernias: mid-term results.

INTRODUCTION: Multiple minimally invasive techniques have been described for ventral hernia repair. The recently described enhanced view totally extraperitoneal (eTEP) ventral hernia repair seems an appealing option since it allows to address midline and lateral hernias, placing the mesh in the retromuscular position without the use of traumatic fixation. AIM: To report on the mid-term result of a series of patients with ventral hernias repaired by the eTEP approach. METHODS: A retrospective analysis of our case series between June 2017 and December 2019. Demographic and clinical data were gathered. Hernia characteristics, surgical details, hernia recurrences, and complications are reported. RESULTS: 66 patients were included in the study. Median follow-up was 22 months (interquartile range 12-26). 60% of patients were male. Mean age, BMI, % of Type-2 diabetes and % of smoking were 59 ± 12 years, 30 kg/m2, 24% and 23%, respectively. Mean hernia defect size was 5.5 ± 2.9 cm. Forty-three eTEP Rives-stoppa and 23 eTEP-Transversus abdominis release (14 unilateral, 9 bilateral) were performed. 22 inguinal hernias and 15 lateral defects were simultaneously repaired. We report 1 recurrence (1.5%) and 10 surgical site occurrences (15%; 6 seromas, 2 hematomas and 2 surgical site infections). Four patients required reinterventions (6%). CONCLUSION: eTEP is a promising approach to treat midline hernias and allows the simultaneous treatment of lateral and inguinal defects, keeping the mesh in the retromuscular position. However, comparative studies must be performed to know its real benefit in laparoscopic ventral hernia repair.

Telemedicine for postoperative follow-up, virtual surgical clinics during COVID-19 pandemic.

Recent coronavirus outbreak and "stay at home" policies have accelerated the implementation of virtual healthcare. Many surgery departments are implementing telemedicine to enhance remote perioperative care. However, concern still arises regarding the safety of this modality in postoperative follow-up after gastrointestinal surgery. The aim of the present prospective study is to compare the use of telemedicine clinics to in-person follow-up for postoperative care after gastrointestinal surgery during COVID-19 outbreak. METHODS: Prospective study that included all abdominal surgery patients operated since the COVID-19 outbreak. On discharge, patients were given the option to perform their postoperative follow-up appointment by telemedicine or by in-person clinics. Demographic, perioperative, and follow-up variables were analyzed. RESULTS: Among 219 patients who underwent abdominal surgery, 106 (48%) had their postoperative follow-up using telemedicine. There were no differences in age, gender, ASA score, and COVID-19 positive rate between groups. Patients who preferred telemedicine over in-person follow-up were more likely to have undergone laparoscopic surgery (71% vs. 51%, P = 0.037) and emergency surgery (55% vs. 41%; P = 0.038). Morbidity rate for telemedicine and in-person group was 5.7% and 8%, (P = 0.50). Only 2.8% of patients needed an in-person visit following the telemedicine consult, and 1.9% visited the emergency department. CONCLUSIONS: In the current pandemic, telemedicine follow-up can be safely and effectively performed in selected surgical patients. Patients who underwent laparoscopic and emergency procedures opted more for telemedicine than in-person follow-up.

Customized bariatric stents for sleeve gastrectomy leak: are they superior to conventional esophageal stents? A systematic review and proportion meta-analysis.

OBJECTIVE: Recently, there has been a burgeoning interest in the utilization of customized bariatric stents (CBS) for management of sleeve gastrectomy leak (SGL). We aimed to conduct a proportion meta-analysis to evaluate the cumulative efficacy and safety of these new stents and to compare them with the conventional esophageal stents (CES). METHODS: A systematic literature search of the PubMed, Cochrane Library, Scopus, Web of Science and Google Scholar databases was conducted through May 1, 2020. Primary outcomes were technical and clinical success and post-procedure adverse events of CBS and CES. Secondary outcomes were number of stents and endoscopic sessions per patient, and time to leak closure. A proportion meta-analysis was performed on outcomes using a random-effects model, and the weighted pooled rates (WPRs) or mean difference with 95% confidence interval (CI) were calculated. RESULTS: The WPR with 95% CI of technical success, clinical success, and stent migration for CBS were 99% (93-100%) I2 = 34%, 82% (69-93%) I2 = 58%, and 32% (17-49%), I2 = 69%, respectively. For CES, the WPR (95% CI) for technical success, clinical success, and stent migration were 100% (97-100%) I2 = 19%, 93% (85-98%) I2 = 30%, and 15% (7-25%), I2 = 41%, respectively. Adverse events other than migration were very low with both types of stents. On proportionate difference, CBS had lower clinical success (11%) and higher migration rate (17%) in comparison to CES. In successfully treated patients, CBS was associated with lower mean number of stents and endoscopic sessions, and shorter time to leak closure compared to CES. The overall quality of evidence was very low. CONCLUSIONS: In treatment of SGL, there is very low level evidence that CES are superior to CBS in terms of clinical success and migration rate, though may require more stent insertions and endoscopic procedures. The evidence however remains very uncertain. Perhaps relevant to some types of stents, CBS are promising; however design modification is strongly recommended to improve outcomes.

Morbidity and Mortality in Patients with Perioperative COVID-19 Infection: Prospective Cohort in General, Gastroesophagic, Hepatobiliary, and Colorectal Surgery.

BACKGROUND: Severe acute respiratory syndrome due to coronavirus 2 has rapidly spread worldwide in an unprecedented pandemic. Patients with an ongoing COVID-19 infection requiring surgery have higher risk of mortality and complications. This study describes the mortality and morbidity in patients with perioperative COVID-19 infection undergoing elective and emergency surgeries. METHODS: Prospective cohort of consecutive patients who required a general, gastroesophageal, hepatobiliary, colorectal, or emergency surgery during COVID-19 pandemic at an academic teaching hospital. The primary outcome was 30-day mortality and major complications. Secondary outcomes were specific respiratory mortality and complications. RESULTS: A total of 701 patients underwent surgery, 39 (5.6%) with a perioperative COVID-19 infection. 30-day mortality was 12.8% and 1.4% in patients with and without COVID-19 infection, respectively (p < 0.001). Major surgical complications occurred in 25.6% and 6.8% in patients with and without COVID-19 infection, respectively (p < 0.001). Respiratory complications occurred in 30.8% and 1.4% in patients with and without COVID-19 infection, respectively (p < 0.001). Mortality due to a respiratory complication was 100% and 11.1% in patients with and without COVID-19 infection, respectively (p < 0.006). CONCLUSIONS: 30-day mortality and surgical complications are higher in patients with perioperative COVID-19 infection. Indications for elective surgery need to be reserved for non-deferrable procedures in order to avoid unnecessary risks of non-urgent procedures.

Small bowel obstruction following laparoscopic Roux-en-Y gastric bypass: is it always necessary to operate? A 5-year, high volume center experience.

PURPOSE: This study aims to describe the incidence, associated factors, etiology, and management of small bowel obstructions following laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: A retrospective analysis was conducted between January 15 and December 19 using the surgery database of our hospital. Included LRYGB patients were those that evolved with a prolonged length of stay; readmission; emergency room consult; and re-intervention due to small bowel obstruction (SBO) related symptoms with compatible radiological or intraoperative findings. The LRYGB technique implied an antecolic alimentary limb reconstruction and systematic closure of mesenteric defects. Descriptive and analytical statistics were carried out, using a parametric or non-parametric approach as needed. RESULTS: Nine hundred forty-one LRYGB were performed. 9.9% were revisional surgeries of patients with a laparoscopic sleeve gastrectomy. During the study period, 36 SBOs occurred, representing 3.8% of operated patients, with no mortality. 58.3% had successful non-operative management, while 41.7% required surgical exploration, of which 73.3% were treated laparoscopically and 20% needed conversion to open surgery. Etiologies of SBO were jejuno-jejunostomy (JJO) related stenosis (22, 61.1%), internal hernias (6, 16.7%), adherences (3, 8.3%), and other diagnoses (5, 13.9%). Regarding JJO stenosis and internal hernias, median time to diagnosis was 8 days (IQR 7-11) and 12 months (IQR 8.7-16) respectively. Previous sleeve gastrectomy, age, or sex was not associated to the incidence of small bowel obstruction. CONCLUSIONS: LRYGB is safe when performed by experienced surgeons. SBO due to internal hernias were scarce in this series. JJO stenosis could explain most cases of SBO; under this diagnosis, non-surgical management was successful frequently.

[Littoral cell angioma of the spleen. Report of one case]. / Angioma de células litorales del bazo. Un diagnóstico de lesión focal esplénica. Caso clínico.

Splenic vascular neoplasms are the most common form of spleen tumors. Among them, littoral cell angioma is rare and it is frequently an incidental finding in imaging studies. It has no specific clinical, laboratory or imaging findings. Splenectomy allows definitive diagnosis throughout a histopathological examination. We report a 52-year-old man presenting with asthenia and abdominal distension. Computed tomography with intravenous contrast showed multiple splenic hypodense masses and a prostatic enlargement. Presuming a lymphoma, a laparoscopic splenectomy was performed. Histopathologic examination diagnosed littoral cell angioma. During urological follow-up, a prostate adenocarcinoma was diagnosed.

Relative lipid oxidation associates directly with mitochondrial fusion phenotype and mitochondria-sarcoplasmic reticulum interactions in human skeletal muscle.

Disturbances in skeletal muscle lipid oxidation might induce ectopic fat deposition and lipotoxicity. Nevertheless, the cellular mechanisms that regulate skeletal muscle lipid oxidation have not been fully determined. We aimed to determine whether there was an association between relative whole body lipid oxidation and mitochondrial size or mitochondria-sarcoplasmic reticulum interactions in the skeletal muscle. Twelve healthy men were included [mean (standard deviation), 24.7 (1.5) yr old, 24.4 (2.6) kg/m2]. The respiratory quotient (RQ) was used to estimate relative lipid oxidation at rest and during exercise (50% maximal oxygen consumption, 600 kcal expended). A skeletal muscle biopsy was obtained from the vastus lateralis at rest. Transmission electron microscopy was used to determine mitochondrial size and mitochondria-sarcoplasmic reticulum interactions (≤50 nm of distance between organelles). Protein levels of fusion/fission regulators were measured in skeletal muscle by Western blot. Resting RQ and exercise RQ associated inversely with intermyofibrillar mitochondrial size (r = -0.66 and r = -0.60, respectively, P < 0.05). Resting RQ also associated inversely with the percentage of intermyofibrillar mitochondria-sarcoplasmic reticulum interactions (r = -0.62, P = 0.03). Finally, intermyofibrillar mitochondrial size associated inversely with lipid droplet density (r = -0.66, P = 0.01) but directly with mitochondria fusion-to-fission ratio (r = 0.61, P = 0.03). Our results show that whole body lipid oxidation is associated with skeletal muscle intermyofibrillar mitochondrial size, fusion phenotype, and mitochondria-sarcoplasmic-reticulum interactions in nondiabetic humans.

Safety and efficacy of the endoscopic duodenal-jejunal bypass liner prototype in severe or morbidly obese subjects implanted for up to 3 years.

BACKGROUND: The duodenal-jejunal bypass liner (DJBL) is an endoscopic device that mimics the duodenal-jejunal exclusion component of the Roux-en-Y gastric bypass. Previous studies assessing the efficacy of the DJBL have shown 10-40% excess weight loss (%EWL) and improvements in obesity-associated comorbidities. The aim of this study was to evaluate the safety and efficacy of a new DJBL prototype over a 3-year period. METHODS: Morbidly obese subjects were enrolled in a single-arm, open-label, prospective trial. The subjects were offered the opportunity to continue with the trial annually and signed a new consent form. The primary endpoint was safety. The secondary endpoints were changes in weight and biochemical parameters from baseline. RESULTS: The DJBL was implanted endoscopically in 80 subjects (age: 35±10 years; 69% female; weight: 109±17 kg; BMI: 42±5.4 kg/m2). Seventy-two severe adverse events (AEs) were observed in 55 patients (68%), of which nine subjects required a prolonged hospital stay and three subjects required major interventions. Overall, 23 subjects (29%) underwent early device removal due to AEs. Additionally, 95% of the patients experienced mild AEs that mainly consisted of abdominal pain. The severe AEs included a liver abscess (3), upper GI bleeding (4), cholangitis (1), and acute pancreatitis (1) and mostly occurred after 12 months of follow-up. Two patients presented a short esophageal perforation during explantation. These perforations were successfully managed with endoscopic closure in one subject and medical treatment in the other subject. In the completer population at 52 weeks (71 patients), 104 weeks (40 patients), and 156 weeks (11 patients), the mean %EWL were 44 ± 16, 40 ± 22, and 39 ± 20, respectively (p < 0.001). CONCLUSION: This study shows significant and sustained weight loss after 3 years of treatment with the new DJBL. However, the high frequency and severity of AEs preclude the use of this prototype for periods longer than 1 year.

Effect of cholecystectomy on hepatic fat accumulation and insulin resistance in non-obese Hispanic patients: a pilot study.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is highly prevalent worldwide. Experimental studies have shown that cholecystectomy (XGB) increases hepatic fat content in mice and appears associated to NAFLD in large retrospective population-based studies. The aim of this study was to prospectively assess the effects of XGB on hepatic fat content (HFC) and insulin resistance (IR) in non-obese, middle aged Hispanic subjects. METHODS: Twenty-six gallstone patients undergoing elective XGB and 16 control subjects with normal livers and gallbladders at ultrasonography were prospectively followed 24 months for changes in HFC and IR. Clinical, biochemical determinations and hepatic imaging were performed at baseline and 24 months after surgery. MRI technique quantified HFC in four hepatic segments. IR was assessed by the Homeostasis Model Assessment (HOMA-IR) index. RESULTS: Initial body mass index (BMI) was 25.6 ± 0.4 and 24.3 ± 1.0 in the control and XGB groups of subjects, respectively. Serum insulin level increased from 8.1 ± 0.7 to 10.0 ± 1.9 (µU/ml) 24 months after surgery in XGB patients (p < 0.05); no significant changes were detected in control individuals. Median HOMA-IR index increased from 1.31 (interquartile range, 1.01-1.68) to 2.20 (interquartile range, 1.57 - 2.60) 24 months after XGB, (p < 0.003). Median HOMA-IR index of control subjects remained unchanged at the end of the study. Serum apoB concentration increased from 61.5 ± 3.4 to 79.0 ± 7.8 (µg/ml) in XGB patients (p < 0.03). Serum apoB levels remained within normal ranges in both periods of the study in control subjects. HFC significantly increased in 2 of the 4 segments 24 months after XGB: right posterior hepatic lobe (from 5.3 ± 0.2% to 6.0 ± 0.2%, p > 0.04) and right anterior hepatic lobe (from 5.8 ± 0.2% to 6.6 ± 0.3%, p < 0.02). The average HFC of the four hepatic segments studied slightly increased from 5.4 ± 0.2 to 5.8 ± 0.3 2 years after XGB (p < 0.03). No significant changes were found in HFC in the control subjects at the end of the study. CONCLUSIONS: Elective XGB increases HFC, HOMA-IR index and serum apoB concentration. These results support the notion that XGB is a risk factor non-alcoholic fatty liver disease and other IR - associated disease conditions.

Bariatric Surgery Before and After the SARS-CoV-2 Pandemic: a Comparative Study of Cases Before the Onset of the Pandemic in a High-Volume Academic Center.

INTRODUCTION: At the beginning of the pandemic, studies showed a higher risk of severe surgical complications and mortality among patients with perioperative SARS-CoV-2 infection, which led to the suspension of elective surgery. Confinement and lockdown measures were shown to be associated with weight gain and less access to medical and surgical care in patients with obesity, with negative health consequences. To evaluate the safety of bariatric surgery during the pandemic, we compared 30-day complications between patients who underwent bariatric surgery immediately before with those who underwent bariatric surgery during the opening phase of the pandemic. METHODS: Observational analytical study of a non-concurrent cohort of patients who underwent bariatric surgery in 2 periods: pre-pandemic March 1 to December 31, 2019, and pandemic March 1 to December 31, 2020. Surgical complications were defined using the Clavien-Dindo classification. RESULTS: Pre-pandemic and pandemic groups included 256 and 202 patients who underwent primary bariatric surgery, respectively. The mean age was 37.6 + 10.3 years. The overall complication rate during the first 30 days of discharge was 7.42%. No differences between groups were observed in severe complications (pre-pandemic 1.56% vs. pandemic 1.98%, p: 0.58). No mortality was reported. Overall 30-day readmission was 3.28% with no differences between groups. CONCLUSION: The findings of this study did not find a difference in the rate of severe complications, nor also we report severe COVID-19 complications in this high-risk population. During the pandemic, with appropriately implemented protocol, the resumption of bariatric surgery is possible with no increased risk for patients.

Five-Year Experience Training Surgeons with a Laparoscopic Simulation Training Program for Bariatric Surgery: a Quasi-experimental Design.

PURPOSE: Nearly 200,000 laparoscopic Roux-en-Y gastric bypass (LRYGB) are performed yearly. Reported learning curves range between 50 and 150, even 500 cases to decrease the operative risk. Simulation programs could accelerate this learning curve safely; however, trainings for LRYGB are scarce. This study aims to describe and share our 5-year experience of a simulated program designed to achieve proficiency in LRYGB technical skills. MATERIALS AND METHODS: A quasi-experimental design was used. All recruited participants were previously trained with basic and advanced laparoscopic simulation curriculum completing over 50 h of practical training. Ex vivo animal models were used to practice manual and stapled gastrojejunostomy (GJ) and stapled jejunojejunostomy (JJO) in 10, 3, and 4 sessions, respectively. The main outcome was to assess the manual GJ skill acquisition. Pre- and post-training assessments using a Global Rating Scale (GRS; max 25 pts), Specific Rating Scale (SRS; max 20 pts), performance time, permeability, and leakage rates were analyzed. For the stapled GJ and JJO, execution time was registered. Data analysis was performed using parametric tests. RESULTS: In 5 years, 68 trainees completed the program. For the manual GJ's pre- vs post-training assessment, GRS and SRS scores increased significantly (from 17 to 24 and from 13 to 19 points respectively, p-value < 0.001). Permeability rate increased while leakage rate and procedural time decreased significantly. CONCLUSION: This simulated training program showed effectiveness in improving laparoscopic skills for manual GJ and JJO in a simulated scenario. This new training program could optimize the clinical learning curve. Further studies are needed to assess the transfer of skills to the operating room.

Higher hepatic advanced glycation end products and liver damage markers are associated with nonalcoholic steatohepatitis.

Advanced glycation end products (AGEs) may be associated with nonalcoholic fatty liver disease (NAFLD) from stimulation of oxidative stress, inflammation, and fibrosis. We hypothesized that patients with NAFLD would have a lower concentration of soluble AGEs receptor and higher quantity of serum and liver AGEs and an increase in hepatic smooth muscle actin alpha (α-SMA) and transforming growth factor beta 1 (TGF-ß1) compared with a control group. We compared the presence of hepatic and serum AGEs, AGE soluble receptor (sRAGE), and markers associated with hepatic damage between NAFLD patients and controls without disease. Histological characteristics, plasma biochemical parameters, serum AGEs, serum receptor sRAGE, and liver proteins (α-SMA, TGF-ß1, AGEs, immunohistochemistry) were assessed in participants aged 18 to 65 years, with NAFLD (simple steatosis [SS]: n = 7; steatohepatitis [NASH]: n = 15) and controls (n = 11). NASH patients presented higher glycated hemoglobin levels (%) (5.7; 5.4-6.3) compared with SS (5.4; 5.2-5.7) and controls (5.4; 5.3-5.5). The NAFLD activity score (NAS) for NASH patients was 4.9 ± 1.3; for SS patients, 2.0 ± 1.0. NASH patients showed higher hepatic AGEs, TGF-ß1, and α-SMA compared with SS and control groups. The NAS score indicates that patients with 5 to 8 had higher hepatic AGEs, TGF-ß1, and α-SMA compared with a NAS of 1 to 4 and 0. For α-SMA, a NAS of 1 to 4 was higher than NAS 0. No difference was found in serum AGEs and sRAGE between groups. Higher hepatic AGEs, TGF-ß1, and α-SMA were observed with increasing disease severity (according to NAS); therefore, endogenous liver AGEs may participate in hepatic damage progression.

Midterm Results of the Open and Minimally Invasive Transversus Abdominis Release Technique for the Treatment of Abdominal Wall Hernias in an Academic Center.

Introduction: Large hernia defects are a challenge for general and specialized hernia surgeons. The transversus abdominis release (TAR) technique has revolutionized the treatment of complex hernias since it allows the closure of large midline hernias, as well as hernias in different locations. This study aims to report the experience with the TAR technique and mid-term results in the first 101 patients. Methods: Non-concurrent cohort review of our prospectively collected electronic database. All patients submitted to a TAR (open or minimally invasive eTEP-TAR) from 2017 to 2020 were included. Demographic data, comorbidities, hernia characteristics, preoperative optimization, intraoperative variables, and clinical outcomes were gathered. The main outcomes of this study are hernia recurrences and surgical morbidity. Results: A total of 101 patients were identified. The median follow-up was 26 months. Mean age and body mass index was 63 years and 31.4 Kg/m2, respectively. Diabetes was present in 22% of patients and 43% had at least one previous hernia repair. Nineteen patients had significant loss of domain. Mean hernia size and area were 13 cm and 247 cm2, respectively. Ninety-six percent of cases were clean or clean-contaminated. The mean operative time was 164 min and all patients received a synthetic mesh. We diagnosed two hernia recurrences and the overall (medical and surgical) complication rate was 32%. The hernia-specific complication rate was 17%, with seven surgical site infections and seven surgical site occurrences requiring procedural interventions. Notably, weight loss was associated with a lower risk of SSOPI and reoperations. Conclusion: We show an encouraging 2% of recurrences in the mid-term follow-up in the setting of clinically complex hernia repair. However, we observed a high frequency of overall and hernia-specific complications pointing to the complexity of the type of surgery itself and the patients we operated on.

Exercise Training to Decrease Ectopic Intermuscular Adipose Tissue in Individuals With Chronic Diseases: A Systematic Review and Meta-Analysis.

OBJECTIVE: The purpose of this study was to evaluate the effect of exercise training on ectopic fat within skeletal muscle (intermuscular adipose tissue [IMAT]) in adult populations with chronic diseases. METHODS: A literature search was conducted in relevant databases to identify randomized controlled trials (RCTs) from inception. Selected studies examined the effect of aerobic training (AET), resistance training (RT), or combined training (COM) on IMAT as assessed by noninvasive magnetic resonance imagery or computed tomography. Eligibility was determined using Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Data extraction was performed using the population (P), intervention (I), comparison (C), outcome (O), timing (T), and settings (S) approach. Methodological quality was analyzed by the Cochrane risk of bias assessment. Standardized effect sizes (ES) with 95% CIs were calculated. Heterogeneity among studies was quantified using I2 statistics. Subgroup and meta-regression analyses were included. Risk of publication bias was examined by the Egger regression test. RESULTS: Nineteen RCTs included 962 adults (628 women; age range = 34.8-93.4 years) with different chronic conditions that participated in 10 AET, 12 RT, and 5 COM interventions. The quality of studies was deemed moderate. Overall, the effect of exercise on IMAT was small (ES = 0.24; 95% CI = 0.10 to 0.37; heterogeneity I2 = 0.0%) compared with no exercise or control interventions. Moderate-intensity AET and COM had larger ES compared with RT regardless of intensity. This effect was associated with exercise-induced body weight and fat mass losses. Subgroup analysis revealed larger ES in studies assessing IMAT by magnetic resonance imagery compared with computed tomography in adults and middle-aged individuals compared with older adults and in participants who were HIV+ compared with other diagnoses. CONCLUSION: AET and COM of moderate intensity reduce IMAT in individuals from 18 to 65 years of age who are affected by chronic diseases. This effect is associated with exercise-induced body weight and fat mass losses. In older individuals who are frail and patients at an advanced disease stage, exercise may result in a paradoxical IMAT accumulation. IMPACT: In people affected by chronic conditions, IMAT accumulation induces muscle mass and strength losses, decline in physical performance, inflammation, and metabolic alterations. The present study shows that moderate-intensity AET or COM prevent or reduce IMAT in these conditions. Thus, the deleterious effect of IMAT on skeletal muscle homeostasis may be reverted by a properly prescribed exercise regime. The findings of the present systematic review are critical for physical therapists and health care professionals because they emphasize the therapeutic role of exercise and provide recommendations for exercise prescription that ultimately may have a positive impact on the course of disease, recovery of functionality, and independence. LAY SUMMARY: Aerobic exercise (eg, walking/jogging, cycling) alone or combined with resistance exercise (strength training with free-weights, kettle bells, or gym equipment) is effective in reducing fat streaks that infiltrate muscles and impair muscle function and growth, particularly in adults affected by chronic diseases.

Insulin resistance and liver histopathology in metabolically unhealthy subjects do not correlate with the hepatic abundance of NLRP3 inflammasome nor circulating IL-1ß levels.

INTRODUCTION: Systemic chronic low-grade inflammation has been linked to insulin resistance (IR) and non-alcoholic steatohepatitis (NASH). NOD-like receptor protein 3 (NLRP3) inflammasome and its final product, interleukin (IL)-1ß, exert detrimental effects on insulin sensitivity and promote liver inflammation in murine models. Evidence linking hepatic NLRP3 inflammasome, systemic IR and NASH has been scarcely explored in humans. Herein, we correlated the hepatic abundance of NLRP3 inflammasome components and IR and NASH in humans. RESEARCH DESIGN AND METHODS: Metabolically healthy (MH) (n=11) and metabolically unhealthy (MUH) (metabolic syndrome, n=21, and type 2 diabetes, n=14) subjects were recruited. Insulin sensitivity (homeostatic model assessment of IR (HOMA-IR) and Oral Glucose Sensitivity (OGIS120)), glycemic (glycated hemoglobin), and lipid parameters were determined by standard methods. Plasma cytokines were quantified by Magpix. Hepatic NLRP3 inflammasome components were determined at the mRNA and protein levels by reverse transcription-quantitative PCR and western blot, respectively. Liver damage was assessed by histological analysis (Non-alcoholic Fatty Liver Disease Activity Score (NAS) and Steatosis, Inflammatory Activity, and Fibrosis (SAF) scores). IR and liver histopathology were correlated with NLRP3 inflammasome components as well as with liver and plasma IL-1ß levels. RESULTS: Body Mass Index, waist circumference, and arterial hypertension frequency were significantly higher in MUH subjects. These patients also had increased high-sensitivity C reactive protein levels compared with MH subjects. No differences in the plasma levels of IL-1ß nor the hepatic content of Nlrp3, apoptosis-associated speck-like (Asc), Caspase-1, and IL-1ß were detected between MUH and MH individuals. MUH subjects had significantly higher NAS and SAF scores, indicating more severe liver damage. However, histological severity did not correlate with the hepatic content of NLRP3 inflammasome components nor IL-1ß levels. CONCLUSION: Our results suggest that NLRP3 inflammasome activation is linked neither to IR nor to the inflammatory status of the liver in MUH patients.

Safety of Bariatric Surgery During the Opening Phase After the First Wave of the COVID-19 Pandemic: Experience at an Academic Center.

INTRODUCTION: Increased morbimortality in patients with COVID-19 infection who had undergone surgery has raised concerns about bariatric surgery safety during the current COVID-19 pandemic. Currently, there is scarce literature on safety outcomes after bariatric surgery during the COVID-19 pandemic. OBJECTIVES: To determine the risk of symptomatic COVID-19 infection and associated complications during the first 30 days after bariatric surgery. MATERIALS AND METHODS: Prospective observational cohort study including all patients who consecutively underwent primary bariatric surgery between August and December 2020. RESULTS: A total of 189 patients were included. Median age and BMI were 36 (17-70) years and 38 (35-41) kg/m2, respectively. Forty percent of patients were women (n = 76), 59.3% (n = 112) underwent sleeve gastrectomy (SG), and 40.7% (n = 77) underwent Roux-en-Y gastric bypass (RYGB). All surgeries were performed laparoscopically. The median length of postoperative stay was 2 (0-5) days. Postoperative COVID-19 infection was detected in two patients (1.1%): one patient was readmitted without the need of intermediate or ICU care, and the other was managed as an outpatient. Major complications occurred in three patients (1.6%); none of them was COVID-19 related. Two patients required an unplanned reoperation. No patient required intermediate or ICU care, no severe COVID-19 complications were observed, and no mortality was reported. CONCLUSION: Bariatric surgery can be safely performed during the ongoing pandemic, albeit a low risk of COVID-19 symptomatic infection. Rigorous perioperative COVID-19 institutional protocols are required to perform bariatric surgery safely during the current pandemic.

Bariatric Surgery in Cirrhotic Patients: a Matched Case-Control Study.

INTRODUCTION: Laparoscopic bariatric surgery (LBS) in liver end-stage organ disease has been proven to improve organ function and patients' symptoms. A series of LBS in patients with cirrhosis have shown good results in weight loss, but increased risk of complications. Current literature is based on clinical series. This paper aims to compare LBS (69% gastric bypass) between patients with cirrhosis and without cirrhosis. METHODS: We conducted a retrospective 1:3 matched case-control study including bariatric patients with cirrhosis and without cirrhosis. Demographics, operative variables, postoperative complications, long-term weight loss, and comorbidity resolution were compared between groups. RESULTS: Sixteen Child A patients were included in the patients with cirrhosis (PC) group and 48 in patients without cirrhosis (control) group. Mean age was 50 years; preoperative BMI was 39 ± 6.8 kg/m2. Laparoscopic gastric bypass and laparoscopic sleeve gastrectomy were performed in 69% and 31%, respectively. Follow-up was 81% at 2 years for both groups. PC group had a higher rate of overall (31% vs. 6%; p < 0.05) and severe (Clavien-Dindo ≥ III; 13% vs. 0%; p = 0.013) complications than that of the control group. Mean %EWL of PC at 2 years of follow-up was 84.9%, without differences compared with that of the control group (83.1%). Comorbidity remission in PC was 14%, 50%, and 85% for hypertension, type 2 diabetes, and dyslipidemia, respectively. Patients without cirrhosis had a higher resolution rate of hypertension (65% vs. 14%, p = 0.03). CONCLUSION: LBS is effective for weight loss and comorbidity resolution in patients with obesity and Child A liver cirrhosis. However, these results are accompanied by significantly increased risk of complications.

Esófago de Barrett: Actualización en el diagnóstico y tratamiento

El esófago de Barrett (EB) se define como la condición en la cual una mucosa columnar metaplásica predispuesta a neoplasia reemplaza la mucosa escamosa del esófago distal. La guías actuales recomiendan que el diagnóstico requiere el hallazgo de metaplasia intestinal (MI) con células caliciformes de al menos 1 cm de longitud. El EB afecta aproximadamente al 1% de la población general y hasta en 14% de los pacientes con enfermedad por reflujo gastroesofágico (ERGE). El EB es precursor del adenocarcinoma esofágico (ACE), neoplasia en aumento en países occidentales. Los principales factores de riesgo descritos para ACE asociado a EB son: sexo masculino, edad > 50 años, obesidad central y tabaquismo. El riesgo anual de ACE en EB sin displasia, displasia de bajo (DBG) y alto grado es 0,1-0,3%, 0,5% y 5-8%, respectivamente. El tratamiento del EB no displásico consiste en un cambio de estilo de vida saludable, quimioprevención mediante inhibidores de la bomba de protones y vigilancia endoscópica cada 3 a 5 años. Se recomienda que a partir de la presencia de DBG los pacientes sean referidos a un centro experto para la confirmación del diagnóstico, estadio y así definir su manejo. En pacientes con EB y displasia o cáncer incipiente, el tratamiento endoscópico consiste en la resección y ablación, con un éxito cercano al 90%. El principal evento adverso es la estenosis esofágica que es manejada endoscópicamente.

Barrett's esophagus (BE) is the condition in which a metaplastic columnar mucosa predisposed to neoplasia replaces the squamous mucosa of the distal esophagus. The current guidelines recommends that diagnosis requires the finding of intestinal metaplasia (IM) with goblet cells of at least 1 cm in length. BE affects approximately 1% of the general population and up to 14% of patients with gastroesophageal reflux disease (GERD). BE is a precursor of esophageal adenocarcinoma (EAC), which has increased in western countries. The main risk factors described for EAC associated with BE are male sex, age > 50 years, central obesity and tobacco use. Annual risk of EAC in patients with BE without dysplasia, low grade (LGD) and high-grade dysplasia is 0,1-0,3%, 0,5% y 5-8%, respectively. Treatment of non-dysplastic BE consists mainly of a healthy lifestyle change, chemoprevention with proton pump inhibitors and surveillance endoscopy every 3 to 5 years. It is recommended that from the presence of LGD patients are referred to an expert center for confirmation of the diagnosis, stage and thus define their management. In patients with BE and dysplasia or early-stage cancer, endoscopic therapy with resection and ablation is successful in about 90% of the patients. The main adverse event is esophageal stricture, which is managed endoscopically.