Comparison of flipped learning and traditional lecture method for teaching digestive system diseases in undergraduate medicine: A prospective non-randomized controlled trial.

INTRODUCTION: This study examined the effects of a large-scale flipped learning (FL) approach in an undergraduate course of Digestive System Diseases. METHODS: This prospective non-randomized trial recruited 404 students over three academic years. In 2016, the course was taught entirely in a Traditional Lecture (TL) style, in 2017 half of the course (Medical topics) was replaced by FL while the remaining half (Surgical topics) was taught by TL and in 2018, the whole course was taught entirely by FL. Academic performance, class attendance and student's satisfaction surveys were compared between cohorts. RESULTS: Test scores were higher in the FL module (Medical) than in the TL module (Surgical) in the 2017 cohort but were not different when both components were taught entirely by TL (2016) or by FL (2018). Also, FL increased the probability of reaching superior grades (scores >7.0) and improved class attendance and students' satisfaction. CONCLUSION: The holistic FL model is more effective for teaching undergraduate clinical gastroenterology compared to traditional teaching methods and has a positive impact on classroom attendances.

Left-sided appendicitis: diagnosis and minimally invasive treatment.

Intestinal malrotation and situs inversus can have important repercussions if acute abdominal pain develops. Intraabdominal structures can have inverted position and thus may easily mislead the surgeon during physical examination. Fortunately, radiological exams have improved the preoperative diagnosis of these patients. However, in difficult cases when an underlying surgical disease is suspected, laparoscopy remains the gold standard in order to diagnose and treat if possible the suspected disorder. We present a case of acute left-side appendicitis in a child with unknown congenital intestinal malrotation. In addition, this case stressed the value of laparoscopy in daily practice to evaluate patients with atypical abdominal pain.

A minimal invasive approach of esophageal liposarcoma.

Esophageal liposarcoma is an extremely rare tumor. Different options of treatment have been advocated. We report the case of a 72-year-old-man with a large tumor resected through left cervicotomy with thoracoscopic assistance. Minimal invasive management of these infrequent tumors and the results of the literature are discussed.

Obesity Surgery Score (OSS) for Prioritization in the Bariatric Surgery Waiting List: a Need of Public Health Systems and a Literature Review.

BACKGROUND: In the last decades, we have experienced an increase in the prevalence of obesity in western countries with a higher demand for bariatric surgery and consequently prolonged waiting times. Currently, in many public hospitals, the only criterion that establishes priority for bariatric surgery is waiting time regardless of obesity severity. METHODS: We propose a new, simple, and homogeneous clinical prioritization system, the Obesity Surgery Score (OSS), which takes into account simultaneously and equitably the time on surgical waiting list and the obesity severity based on three variables: body mass index, obesity-related comorbidities, and functional limitations. We have reviewed the current literature related to obesity clinical staging systems, and we have carried out an analysis of our patients in waiting list and divided their characteristics according to their degree of severity (A, B, or C) in the OSS. Patients with OSS grade C have a higher mean BMI, greater severity in comorbidities, and greater socio-labor impact. The current surgery waiting time of our series is of 26 months. Currently, 27 patients (51.9%) with OSS grade B and 15 patients (51.7%) with OSS grade C have been on our waiting list for more than 1 year. CONCLUSION: Since the obesity severity, the waiting time and its clinical consequences are associated with an increase in morbidity and mortality, it is important to apply a structured prioritization system for bariatric surgery waiting list. This allows prioritization of patients at greater risk, improves patient prognosis, and optimizes costs and available health resources.

[Atraumatic rupture of the spleen: experience of 10 cases]. / Rotura no traumática del bazo: experiencia con 10 casos.

The most common cause of splenic rupture is trauma. Less frequently the spleen ruptures due to an ongoing hematologic, infectious or tumoral disease (pathologic rupture). We present a series of 10 patients with atraumatic splenic rupture: in seven patients there was a pathologic rupture. Two of the remaining three patients with spontaneous rupture were morbidly obese; this association has not previously been reported. The present review discusses the etiology, pathogenesis and optimal treatment of this entity.

Impact of previous abdominal surgery on colorectal laparoscopy results: a comparative clinical study.

To assess the results of laparoscopic colorectal surgery in patients who have previously undergone abdominal surgery. Between November 2002 and June 2004, 86 patients underwent laparoscopic surgery for colorectal disease at our hospital. Patients were divided into 2 groups depending on whether they had previously undergone abdominal surgery (previous surgery group, n = 27) or not (nonprevious surgery group, n = 59). Data were prospectively collected for statistical analyses of demographic, clinical, and histologic variables. Groups were comparable in age, body mass index, American Society of Anesthesiologists score, diagnosis, technique performed, and tumor size and distance to anal verge. There was no difference in perioperative complication rates. A higher conversion rate was found in the previous surgery group (26.1% vs. 5.1%, P = 0.02). In patients with tumor diseases, resection evaluations were no different regarding specimen length, distal and radial resection margins, or number of lymph nodes harvested. Laparoscopic colorectal surgery has proved to be a reliable technique for patients who have previously undergone abdominal surgery, its results comparable to those obtained with patients who have not.

Frequency of abnormal esophageal acid exposure in patients eligible for bariatric surgery.

BACKGROUND: Obesity and gastroesophageal reflux disease (GERD) are both high-prevalence diseases in developed nations. Obesity has been identified as an important risk factor in the development of GERD. The objective of this study was to determine the frequency of abnormal esophageal acid exposure in patients candidate for bariatric surgery and its relationship with any clinical and endoscopic findings before surgery. METHODS: Data collected from a group of 88 patients awaiting bariatric surgery included a series of demographic variables and symptoms typical of GERD. The tests patients underwent included manometry, pH monitoring, and upper gastrointestinal endoscopy. Univariate and multivariate analyses were conducted on the variables related to the onset of reflux. RESULTS: Esophageal pH monitoring tests were positive in 65% of the patients. Manometries showed lower esophageal sphincter hypotonia in 46%, while 20% returned abnormal upper endoscopy results. Out of the 45% of patients who were asymptomatic or returned normal endoscopies, half returned positive esophageal pH tests. In turn, among the 55% of patients who had symptoms or an abnormal upper endoscopy, three quarters had pH tests that diagnosed reflux. pH tests were also positive in 80% of symptomatic patients and 100% of patients with esophagitis (P<.042). No statistically significant relationship was found between body mass index, sex, age, manometry, or hiatus hernia and the positive pH monitoring. CONCLUSION: Frequency of abnormal esophageal acid exposure among obese patients is high. There is a relationship between the presence of symptoms and reflux. But the absence of symptoms does not rule out the presence of abnormal esophageal function tests.

A revolutionary design change to improve stapler safety.

BACKGROUND: Postoperative staple line leaks and bleeding are the most common reasons for complications in surgical procedures that involve organ resection, such as sleeve gastrectomy. Increasing the safety of these operations requires improving the instruments (endostaplers or endocutters) used for stapling and sectioning the tissues. METHODS: We present a new prototype stapler for marketing in resection surgery, especially designed for the sleeve gastrectomy. RESULTS: We suggest that the medical instrument industry creates devices in which the channel along which the knife blade runs is located asymmetrically. This would allow more staples to be placed on the side of the gastric remnant, thus improving the sealing and hemostasis of the suture line and reducing the number of complications for patients as a result. CONCLUSIONS: The application of new concepts in medical surgical devices can improve the safety of the procedures in our patients.

Single-incision laparoscopic surgery for colon and rectal cancer: an initial experience with the technique.

BACKGROUND: Single-incision laparoscopic surgery seems destined to take its place in the evolution of minimally invasive surgery. Although isolated cases have been reported in the literature, no series has yet been published on the use of this approach to treat colorectal cancer. We describe the surgical technique and perioperative outcomes of this approach in 15 patients diagnosed for colorectal cancer. METHODS: We have used several devices to gain transumbilical access to the abdominal cavity, usually working with 3 cannulae to insert the instruments. We used a 5 mm endograsper, and articulated rotating (roticulating) endoscissors and endodissector to assist dissection. Vascular control and section of the rectum were performed using roticulating endostaplers. We combined the use of curved and straight instruments as required for each step during surgery. The dissection technique performed was the same as the one we normally use in conventional laparoscopy. Specimens were extracted through the umbilical incision. RESULTS: The most commonly performed procedure was sigmoidectomy (n=7), followed by high anterior resection of the rectum (n=5). The mean surgical time was 185±44.9 minutes. The mean hospital stay was 6.2±4.7 days. Three cases (20%) were converted to conventional laparoscopy. Surgery was curative in all of the patients. CONCLUSIONS: Single-access transumbilical laparoscopic surgery is feasible and safe for treating colorectal carcinoma when performed by surgeons with ample experience in laparoscopic colorectal resection. Further studies are needed to determine the advantages and drawbacks of this procedure.

Gastroesophageal junction leak with serious sepsis after gastric bypass: successful treatment with endoscopy-assisted intraluminal esophageal drainage and self-expandable covered metal stent.

We present a case of gastroesophageal junction leak after gastric bypass with serious sepsis and hemodynamic instability. Minimally invasive treatment was performed in two stages: initial sepsis control by lavage and endoscopy-assisted laparoscopic placement of an intraluminal esophageal drainage tube through the leak orifice; this was followed by definitive leak treatment with a self-expandable covered metal stent after achieving hemodynamic stability. Patient evolution was satisfactory without the need for open surgery.

Which patients benefit most from laparoscopic ventral hernia repair? A comparative study.

PURPOSE: To establish which patients suffering ventral hernia benefit the most from laparoscopic approach. METHODS: From January 2005 to October 2008, 126 patients underwent surgery due to incisional hernia at our University Hospital. Patients were assigned to laparoscopic surgery (n=60) or conventional surgery (n=66) at the surgeon's discretion. Patients were subdivided according to the greater diameter of the defect: (G1, defect <5 cm; G2, defect 5 to 15 cm; and G3, defect >15 cm). Data on patient demographic, clinical, and perioperative variables were collected prospectively. RESULTS: Groups were comparable in terms of sex, body mass index, American Society of Anesthesiologists score, size of defect, and proportion of primary repairs. Four patients were converted to open surgery. Mean hospital stay in the group with the smaller hernias (G1 was 3.16 d laparoscopic surgery vs. 2.87 d conventional surgery, P>0.05). Hospital stay for patients who underwent laparoscopy was shorter in G3 (4.25 d Lap vs. 12.6 d Open; P=0.02). CONCLUSIONS: Patients with very large incisional hernias are those who benefit the most from laparoscopic treatment.

Outcomes after laparoscopic treatment of complicated versus uncomplicated acute appendicitis: a prospective, comparative trial.

BACKGROUND: Laparoscopic treatment of simple acute appendicitis (AA) is a safe procedure; however, there are doubts about its safety in cases of complicated AA. The aim of this study was to determine the differences in results of laparoscopic treatment between cases of complicated versus simple AA. MATERIALS AND METHODS: We prospectively included all patients treated for suspected AA by two surgeons of our service between May 2002 and May 2007. Of 221 patients, 20 were excluded from the study because the laparoscopic approach was not possible; 116 of 201 had uncomplicated AA, 57 complicated AA, 12 gynecologic ethiology, 11 negative appendectomy, and 5 other causes; patients without acute appendicitis were also excluded from the study. In all cases, laparoscopy was the first treatment option. The following variables were considered: mean surgical time, reconversions, emergency readmissions, emergency reinterventions or invasive procedures, mean postoperative hospital stay, and postoperative complications (i.e., infectious or noninfectious). RESULTS: Our results showed statistically significantly worse results, in terms of surgical time, postoperative stay, reconversions, and infectious complications, for patients with complicated versus uncomplicated AA; however, no differences were observed regarding noninfectious complications, emergency readmissions, and emergency reinterventions or invasive procedures. CONCLUSIONS: We consider that laparoscopic treatment of complicated AA may be safely used, despite worse results than in cases of simple AA, since the differences in numbers of severe postoperative complications requiring emergency readmission, reintervention, or invasive procedures were not statistically significant.

Hepatolitiasis en la fibrosis quística: una condición especial para el tratamiento quirúrgico / Hepatolithiasis in cystic fibrosis: A special condition for surgical treatment

No disponible

Tratamiento del fallo hepático después de hepatectomía mediante sistema de diálisis hepática MARS / Treatment of hepatic failure after hepatectomy by the MARS hepatic dialysis system

No disponible

Posttraumatic Intrasplenic Pseudoaneurysm with High-Flow Arteriovenous Fistula: New Lessons to Learn.

Intrasplenic pseudoaneurysm is a potentially lethal complication of abdominal trauma. We present the case of a 33-year-old patient with this particular complication diagnosed by CT-scan. Selective embolization was not possible due to its extraordinarily large size and finally splenectomy was performed. We review the English literature and discuss the particular role of the interventional radiologist to treat this entity. The interventional radiologist is the specialist who better estimates the success of embolization or the risk and possibility of delayed splenic rupture. Embolization of the arterial tributary to the pseudoaneurysm should be considered as the treatment of choice only when the diagnosis is made before rupture of the spleen and only in selected cases. Splenectomy always remains as an alternative treatment for high-risk pseudoaneurysms.

[Mesenteric closure in laparoscopic gastric bypass: surgical technique and literature review]. / Cierre mesentérico en el bypass gástrico laparoscópico: técnica quirúrgica y revisión de la literatura.

Despite the advantages offered by laparoscopy in bariatric surgery, the incidence of a new complication that was uncommon in the previous era of open surgery--internal hernias--has increased. Most publications in the literature dealing with internal hernia describe the incidence and form of presentation of this entity but few explain how these complications can be prevented. In this review article we describe a technique to close mesenteric defects in retrocolic Roux-en-Y laparoscopic gastric bypass with permanent, continuous running suture (ethibond). We also review the literature in MEDLINE (www.ncbi.nlm.nih.gov/entrez/ using the key words: obesity, laparoscopy, gastric bypass, internal hernia, Petersen hernia) and references from articles of interest to determine the real incidence of this complication. Our technique has proven to be safe, reliable and reproducible and has greatly diminished the incidence of internal hernias. However, our data need to be analyzed in the future to determine whether the technique described eliminates this complication. The optimal results achieved with complete closure of all mesenteric defects have also been observed by other authors.

[Localization of gastrointestinal bleeding from jejunal diverticuli by methylene blue dye]. / Localización con azul de metileno de la hemorragia digestiva originada en divertículos yeyunales.

Localization of digestive hemorrhage is essential for the management of this entity. However, management is difficult in the small bowel, where emergency situations are rare but may require surgery without precise location of the lesion. We present a case of hemorrhage caused by jejunal diverticulum diagnosed by angiography. A highly selective microcatheter was placed in the bleeding site to achieve staining of the lesion with intraoperative methylene blue.