Multi-institutional expert update on the use of laparoscopic bile duct exploration in the management of choledocholithiasis: Lesson learned from 3950 procedures.

BACKGROUND: Recently there has been a growing interest in the laparoscopic management of common bile duct stones with gallbladder in situ (LBDE), which is favoring the expansion of this technique. Our study identified the standardization factors of LBDE and its implementation in the single-stage management of choledocholithiasis. METHODS: A retrospective multi-institutional study among 17 centers with proven experience in LBDE was performed. A cross-sectional survey consisting of a semi-structured pretested questionnaire was distributed covering the main aspects on the use of LBDE in the management of choledocholithiasis. RESULTS: A total of 3950 LBDEs were analyzed. The most frequent indication was jaundice (58.8%). LBDEs were performed after failed ERCP in 15.2%. The most common approach used was the transcystic (63.11%). The overall series failure rate of LBDE was 4% and the median rate for each center was 6% (IQR, 4.5-12.5). Median operative time ranged between 60-120 min (70.6%). Overall morbidity rate was 14.6%, with a postoperative bile leak and complications ≥3a rate of 4.5% and 2.5%, respectively. The operative time decreased with experience (P = .03) and length of hospital stay was longer in the presence of a biliary leak (P = .04). Current training of LBDE was defined as poor or very poor by 82.4%. CONCLUSION: Based on this multicenter survey, LBDE is a safe and effective approach when performed by experienced teams. The generalization of LBDE will be based on developing training programs.

[Influence of the lockdown due to COVID-19 on weight-loss results during the first year after sleeve gastrectomy]. / Influencia del confinamiento por COVID-19 en los resultados ponderales durante el primer año tras la gastrectomía vertical.

INTRODUCTION: COVID-19 pandemic has lead to lockdown of population in many countries. In Spain, the state of alarm was established from March 15 to June 20, 2020. Usually this fact decreased people's mobility and physical activity, in addition to producing or exacerbating psychological disorders. Our aim was to determine the influence that this condition had over the short-term ponderal results of patients undergoing laparoscopic vertical gastrectomy from May 2019 to May 2020. METHODS: Case-control study for comparing the percentage of excess weight lost (%EWL) and the percentage of total weight lost (%TWL) of patients that underwent a VG during the last year, so they were affected by lockdown in April and part of March 2020 (group 1), to the %EWL and %TWL of a control group (group 2), obtained from our previous series. RESULTS: The mean %EWL in group 1 is 47,37 ± 18,59 and in group 2 is 51,13 ± 17,59, being p = 0,438. Meanwhile, the mean %TWL in group 1 is 21,14 ± 8,17 and in group 2 is 24,67 ± 8,01, with p = 0,115. CONCLUSIONS: Population lockdown by COVID-19 did not get worse short-term results of vertical gastrectomy. More studies with a larger number of patients are necessary to draw firm conclusions.

Influence of the lockdown due to COVID-19 on weight-loss results during the first year after sleeve gastrectomy.

INTRODUCTION: COVID-19 pandemic has lead to lockdown of population in many countries. In Spain, the state of alarm was established from March 15 to June 20, 2020. Usually this fact decreased people's mobility and physical activity, in addition to producing or exacerbating psychological disorders. Our aim was to determine the influence that this condition had over the short-term ponderal results of patients undergoing laparoscopic vertical gastrectomy from May 2019 to May 2020. METHODS: Case-control study for comparing the percentage of excess weight lost (%EWL) and the percentage of total weight lost (%TWL) of patients that underwent a VG during the last year, so they were affected by lockdown in April and part of March 2020 (group 1), to the %EWL and %TWL of a control group (group 2), obtained from our previous series. RESULTS: The mean %EWL in group 1 is 47.37±18.59 and in group 2 is 51.13±17.59, being P=.438. Meanwhile, the mean %TWL in group 1 is 21.14±8.17 and in group 2 is 24.67±8.01, with P=.115. CONCLUSIONS: Population lockdown by COVID-19 did not get worse short-term results of vertical gastrectomy. More studies with a larger number of patients are necessary to draw firm conclusions.

[Giant lipomas or retroperitoneal liposarcomas? Controversies in their diagnosis and treatment]. / ¿Lipoma gigante o liposarcoma retroperitoneal? Controversias en su diagnóstico y tratamiento.

BACKGROUND: Retroperitoneal lipomas are extremely rare tumors that must be differentiated from well-differentiated liposarcomas (WD-LPS). OBJECTIVES: To summarize the evidence about giant retroperitoneal lipomas or liposarcomas; and to elaborate recommendations for their management. DATA SOURCES: A systematic literature search from January 1985 to December 2019 and a review of our own cases was performed. RESULTS: Our series comprises four patients, two females and two males. The diagnosis was incidental in two cases. The medium size was 26 cm, being two cases located exclusively in the retroperitoneum, one in the inguinal region and one in the buttock via pelvic space. All cases were surgically removed being confirmed the initial diagnosis of retroperitoneal lipomas in two cases, as the rest two cases were classified as WD_LPS after MDM2/CDK4 genetic analysis. The review of the available literature plus our own cases revealed 30 cases, of which 58% were woman. Only two cases were asymptomatic. The main symptom was abdominal mass (53%) followed by abdominal pain (40,6%). The median size of the lesions was 24,9 cm with a median weight of 4.576,3 g. All cases were surgically removed, being necessary to remove contiguous organs in only four cases (12,5%). CONCLUSIONS: Retroperitoneal lipoma is a rare tumor which must be differentiated from WD-LPS. This is a very difficult task, being necessary to determinate MDM2 status (by FISH or MLPA), present in liposarcoma but not in lipomas, for its correct diagnosis. The treatment must be based on a complete surgical resection with negative margins.

Evolution of gastroesophageal reflux after laparoscopic vertical gastrectomy. A radiographic, manometric and pH-metric study.

INTRODUCTION: the relationship between laparoscopic vertical gastrectomy (LVG) and gastroesophageal reflux (GER) is still controversial. Therefore, its study is of great interest in order to obtain definitive conclusions. The goal of the study was to establish whether LVG modifies pH-metric GER in obese patients and to analyze the associated factors. PATIENTS AND METHODS: the first 26 patients who underwent LVG in our institution were enrolled in the study. A barium swallow, 24-hour ambulatory pH-metry and four-channel intraluminal esophageal manometry (IEM) were all performed before and one year after surgery. RESULTS: among the pH-metric data, there was a significant increase in the DeMeester index after the procedure (p = 0.028), while other parameters remained unchanged. Furthermore, 50% of patients with preoperative pH-metric GER had normal values at one year after surgery. IEM showed a decrease in lower esophageal sphincter (LES) pressure and in the mean wave amplitude at the distal third of the esophagus (p = 0.007 and p = 0.025, respectively). The rate of newly-developed hiatal hernias in the radiographic study was 36.4%. CONCLUSION: LVG mildly increases GER, which is likely related to the development of hiatal hernias and a decrease in LES pressure and esophageal sweep. However, LVG should not be contraindicated for patients with preoperative pH-metric GER, as this may clear after the procedure.

Open versus minimally invasive liver surgery for colorectal liver metastases (LapOpHuva): a prospective randomized controlled trial.

OBJECTIVE: To present surgical and oncological outcomes using a prospective and randomized trial (LapOpHuva, NCT02727179) comparing minimally invasive liver resection (LLR) versus open liver resection (OLR) in patients with colorectal liver metastases (CRLM). METHODS: Between February 2005 and March 2016, 204 selected patients with CRLM were randomized and 193 were included: LLR (n = 96) and OLR (n = 97). The primary endpoint was to compare postoperative morbidity. Other secondary endpoints were oncological outcomes, use of the Pringle maneuver, surgical time, blood losses, transfusions, hospital stay, mortality and OS, and disease-free survival (DFS) at 3, 5, and 7 years. RESULTS: LLR presented with lower global morbidity (11.5% vs. 23.7%, p = 0.025) but with similar severe complications. Long-term survival outcomes were similar in both groups. The cumulative 1-, 3-, 5-, 7-year OS for LLR and OLR were 92.5%, 71.5%, 49.3%, 35.6% versus 93.6%, 69.7%, 47.4%, 35.5%, respectively (log-rank = 0.047, p = 0.82). DFS for LLR and OLR was 72.7%, 33.5%, 22.7%, and 20.8% versus 61.6%, 27.2%, 23.9%, and 17.9%, respectively (log-rank = 1.427, p = 0.23). LLR involved more use of the Pringle maneuver (15.5% vs. 30.2%, p = 0.025) and a shorter hospital stay (4 vs. 6 days, p < 0.001). There were no differences regarding surgical time, blood losses, transfusion, and mortality. CONCLUSIONS: In selected patients with CRLM, LLR presents similar oncological outcomes with the advantages of the short-term results associated with LLR.

Massive spontaneous hemothorax in patients with neurofibromatosis type 1. / Hemotórax masivo espontáneo en pacientes con neurofibromatosis tipo 1.

OBJECTIVES: Spontaneous hemothorax is an uncommon event that can occur in patients with a history of neurofibromatosis type 1 because of intrathoracic vascular malformations that predispose to aneurysms or bleeding from thoracic tumors. Only 53 cases of this rare association have been reported in the literature since 1975. We described 2 cases: one patient was a 73-year-old man with a right hemothorax secondary to an intercostal neurofibroma; the other was a 35-year-old woman with a left hemothorax secondary to a neurofibroma that compromised the internal mammary artery. Our review of the literature found that 61.8% of cases involved women with a mean age of 43.9 years. There was a certain tendency toward left-sided (56.4%) hemothorax, and the intercostal space was the most common site of bleeding. Treatment was most often surgical (58.2%) in reported cases, although selective artery embolization is also a valid choice. Exitus occurred during 30.9% of the reported episodes, and survival was higher in patients who were treated with surgery or arterial embolization than in those in whom only a thoracic drain was placed or who received no invasive treatment (P=.02).

ES: El hemotórax espontáneo es una entidad poco frecuente que en los pacientes con antecedentes de neurofibromatosis tipo 1 (NF1) puede ser debido a malformaciones vasculares intratorácicas que predisponen a formaciones aneurismáticas o bien a sangrado de tumores torácicos. Esto ocurre en muy raras ocasiones, con solo 53 casos reportados en la bibliografía desde 1975. Presentamos dos casos: el primero, un varón de 73 años con hemotorax derecho secundario a un neurofibroma intercostal; el segundo, una mujer de 35 años con hemotórax izquierdo secundario a un neurofibroma que lesionaba la arteria mamaria interna. Revisando la bibliografía, el 61,8% son mujeres con una edad media de 43,9 años, y con cierta predisposición a la localización en el hemitórax izquierdo (56,4%). El paquete intercostal es el más frecuentemente involucrado en el sangrado. La cirugía ha sido el tratamiento realizado con mayor frecuencia (58,2%), si bien la embolización a través de arteriografía selectiva es un tratamiento válido. Un 30,9% fallecieron durante el episodio y aquellos tratados con cirugía o embolización arteriográfica tienen una mayor supervivencia que aquellos pacientes a los que no recibieron tratamiento invasivo o bien solo se les colocó un drenaje torácico (p = 0,02).