Impact of Neoadjuvant Treatment on Body Composition in Patients with Locally Advanced Gastric Cancer.

Neoadjuvant chemotherapy (NT) followed by radical surgery is the standard treatment for locally advanced gastric cancer (GC). The incidence of sarcopenia in upper gastrointestinal tract malignancies is very high, and it may be increased after NT. This study aimed to evaluate the impact of NT on body composition. A retrospective study of patients with locally advanced GC undergoing gastrectomy who had received NT in a tertiary hospital between 2012 and 2019 was conducted. CT measured the skeletal muscle index, total psoas area, and visceral and subcutaneous adipose tissue before and after NT. Of the 180 gastrectomies for GC, 61 patients received NT. During NT, changes in body composition were observed with a decrease in the skeletal muscle mass index (SMMI -2.5%; p < 0.001), and these changes were significantly greater in men (SMMI -10.55%). Before surgery, patients who received NT presented 15% more sarcopenia than those without NT (p = 0.048). In conclusion, patients with locally advanced gastric cancer who receive NT have significant changes in body composition during chemotherapy. These changes, which are at the expense of a loss of muscle mass, lead to an increased incidence of pre-surgical sarcopenia.

Risk factors associated with radiological and clinical recurrences after laparoscopic repair of large hiatal hernia with TiO2Mesh™ reinforcement.

INTRODUCTION: Laparoscopic repair of large para-esophageal hiatal hernias (LPHH) remains controversial. Several meta-analyses suggest hiatus reinforcement with mesh has better outcomes over cruroplasty in terms of less recurrence. The aim of this study was to evaluate the medium-term results of treating LPHH with a biosynthetic monofilament polypropylene mesh coated with titanium dioxide to enhance biocompatibility (TiO2Mesh™). METHODS: A retrospective observational study, using data extracted from a prospectively collected database was performed at XXX from December 2014 to June 2023. Included participants were all patients who underwent laparoscopic repair of large (> 5 cm) type III hiatal hernia in which a TiO2Mesh™ was used. The results of the study, including clinical and radiological recurrences as well as mesh-related morbidity, were analyzed. RESULTS: Sixty-seven patients were finally analyzed. Laparoscopic approach was attempted in all but conversion was needed in one patient because of bleeding in the lesser curvature. With a median follow-up of 41 months (and 10 losses to follow-up), 22% of radiological recurrences and 19.3% of clinical recurrences were described. Regarding complications, one patient presented morbidity associated with the mesh (mesh erosion requiring endoscopic extraction). Recurrent hernia repair was an independent factor of clinical recurrence (OR 4.57 95% CI (1.28-16.31)). CONCLUSION: LPHH with TiO2Mesh™ is safe and feasible with a satisfactory medium-term recurrence and a low complication rate. Prospective randomized studies are needed to establish the standard repair of LPHH.

Impact of Sarcopenic Obesity on Long-Term Cancer Outcomes and Postoperative Complications After Gastrectomy for Gastric Cancer.

BACKGROUND: The prevalence of sarcopenia in gastric cancer (GC), although varying among the reported studies, is around 60%. In the last few years, it has been recognised that sarcopenia can also occur not only in patients with weight loss and low body weight, but also in patients with normal or increased body mass index. Therefore, the term sarcopenic obesity (SO) is a new definition that further expands the implications of altered body composition. The aim of this study was to assess the impact of SO on the perioperative morbidity and the survival of GC patients undergoing gastrectomy by evaluating body composition on CT images. METHODS: Preoperative CT scans were obtained from all patients with a diagnosis of GC undergoing gastrectomy with curative intent between January 2012 and December 2019. Skeletal muscle mass index (SMMI) and visceral adipose tissue (VAT) cross-sectional area at the level of the transverse processes of the third lumbar vertebra (L3) were measured. Sarcopenia and obesity were defined according to sex-specific cut-off points. RESULTS: After analysing 190 patients, the prevalence of SO was 21.1% (40 patients) and sarcopenia was 14.7% (28 patients). Multivariate analysis showed that corporal composition was an independent factor of overall survival (p = 0.049). Logistic regression was performed to identify risk factors associated with postoperative complications. SO was identified as a risk factor for serious Clavien-Dindo complications > IIIb/IV [OR 2.82 (1.1-7.1); p = 0.028]. CONCLUSION: SO was a risk factor for severe postoperative complications as well as worse long-term oncological after a gastrectomy for GC.

The Beneficial Changes on Inflammatory and Endothelial Biomarkers Induced by Metabolic Surgery Decreases the Carotid Intima-Media Thickness in Men.

Obesity increases cardiovascular risk in men through several mechanisms. Among them, low-grade chronic inflammation and obesity-associated hypogonadism have been described. We aimed to study the effects of metabolic surgery on the carotid-intima media thickness through changes in inflammatory, endothelial biomarkers, and testosterone. We included 60 men; 20 submitted to laparoscopic Roux-en-Y gastric bypass (RYGB), 20 to sleeve gastrectomy (SG), and 20 to lifestyle modification (controls). Several inflammatory and endothelial biomarkers and total testosterone (TT) were measured at baseline and six months after surgery. Free testosterone (FT) was calculated, and carotid intima-media thickness (cIMT) was measured by ultrasonography. Compared to controls, cIMT decreased after surgery concomitantly with CRP, PAI-1, sICAM-1, and IL-18 (p < 0.01) and with an increase in sTWEAK (p = 0.027), with no differences between RYGB and SG. The increase in TT and FT after surgery correlated with the changes in cIMT (p = 0.010 and p = 0.038, respectively), but this association disappeared after multivariate analysis. Linear regression showed that sTWEAK (ß = -0.245, p = 0.039), PAI-1 (ß = 0.346, p = 0.005), and CRP (ß = 0.236, p = 0.049) were associated with the changes in cIMT (R2 = 0.267, F = 6.664, p = 0.001). In conclusion, both RYGB and SG induced improvements in inflammation and endothelial biomarkers that drove a decrease in cIMT compared to men with obesity who submitted to diet and exercise.

Dose-escalated neoadjuvant chemoradiotherapy for locally advanced oesophageal or oesophagogastric junctional adenocarcinoma.

Background: Neoadjuvant chemoradiotherapy with CROSS-protocol is the standard of care for locally advanced esophageal cancer. The purpose of this study was to demonstrate an improvement in complete pathological response (ypCR) after a dose-escalation neoadjuvant protocol compared to standard treatment. Secondary endpoints were disease-free survival (DFS) and acute gastrointestinal toxicity. Material and methods: We prospectively evaluated patients with locally advanced esophageal adenocarcinoma who received neoadjuvant chemoradiotherapy. The radiation dose was 41.4 Gy in 23 fractions or 50.4 Gy in 28 fractions with weekly administration of six intravenous cycles of carboplatin AUC 2 mg/mL and intravenous paclitaxel 50 mg/m2 followed by surgery. Results: Between December 2015 and July 2020, 21 patients were treated according to the reported radiation schedules. Median age was 61 years (57-67). 20 (95.2%) tumors were located at the esophagogastric junction and 1 (4.8%) in the middle esophagus. Five (23.8%) were stage II and 16 (76.2%) stage III. Twelve (57.1%) patients received 41.4 Gy (standard group) and 9 (42.9%) received 50.4 Gy (intensification group), with 5 (41.67%) and 5 (55.6%) presenting ypCR in the standard and intensification group, respectively (p = 0.67). After a median follow-up of 17 months (8-30), DFS in the standard group was 17.78 months [95% (CI, confidence interval): 12.9-22.6] and 45.5 months (95% CI: 24.4-66.05) in the intensification group (p = 0.299). Grade III acute gastrointestinal toxicity was 16% and 33.33%, respectively (p = 0.552). Postoperative toxicity events ≥ Grade III were 5 (41.7%) and 4 (44.4%), respectively (p = 0.623). Conclusions: In our study we found a trend towards a higher complete pathological response-rate and disease-free survival in the intensification group compared to the standard group, with no differences in gastrointestinal toxicity. Well-designed randomized and controlled trials are needed to obtain conclusive data.

The Role of Adiponectin in the Resolution of Male-Obesity-Associated Secondary Hypogonadism after Metabolic Surgery and Its Impact on Cardiovascular Risk.

Male-obesity-associated secondary hypogonadism (MOSH) is a very prevalent entity that may resolve after marked weight loss. Adiponectin (APN) is an adipokine with anti-inflammatory properties that regulates metabolism. Low-circulating APN is associated with obesity, diabetes, and cardiovascular risk, along with circulating testosterone. We aimed to evaluate APN changes in men with MOSH (low circulating free testosterone (FT) with low or normal gonadotropins) and without it after metabolic surgery. We look for their possible association with cardiovascular risk measured by carotid intima-media thickness (cIMT). We included 60 men (20 submitted to lifestyle modification, 20 to sleeve gastrectomy, and 20 to gastric bypass) evaluated at baseline and 6 months after. The increase in APN at follow-up was reduction in patients with persistent MOSH (n = 10) vs. those without MOSH (n = 30) and MOSH resolution (n = 20), and the former did not achieve a decrease in cIMT. The increase in APN correlated positively with FT (r = 0.320, p = 0.013) and inversely with cIMT (r = -0.283, p = 0.028). FT inversely correlated with cIMT (r = -0.269, p = 0.038). In conclusion, men without MOSH or with MOSH resolution showed a high increase in APN after weight loss with beneficial effects on cIMT. Those without MOSH resolution failed to attain these effects.

GECOP-MMC: phase IV randomized clinical trial to evaluate the efficacy of hyperthermic intraperitoneal chemotherapy (HIPEC) with mytomicin-C after complete surgical cytoreduction in patients with colon cancer peritoneal metastases.

BACKGROUND: The French PRODIGE 7 trial, published on January 2021, has raised doubts about the specific survival benefit provided by HIPEC with oxaliplatin 460 mg/m2 (30 minutes) for the treatment of peritoneal metastases from colorectal cancer. However, several methodological flaws have been identified in PRODIGE 7, specially the HIPEC protocol or the choice of overall survival as the main endpoint, so its results have not been assumed as definitive, emphasizing the need for further research on HIPEC. It seems that the HIPEC protocol with high-dose mytomicin-C (35 mg/m2) is the preferred regime to evaluate in future clinical studies. METHODS: GECOP-MMC is a prospective, open-label, randomized, multicenter phase IV clinical trial that aims to evaluate the effectiveness of HIPEC with high-dose mytomicin-C in preventing the development of peritoneal recurrence in patients with limited peritoneal metastasis from colon cancer (not rectal), after complete surgical cytoreduction. This study will be performed in 31 Spanish HIPEC centres, starting in March 2022. Additional international recruiting centres are under consideration. Two hundred sixteen patients with PCI ≤ 20, in which complete cytoreduction (CCS 0) has been obtained, will be randomized intraoperatively to arm 1 (with HIPEC) or arm 2 (without HIPEC). We will stratified randomization by surgical PCI (1-10; 11-15; 16-20). Patients in both arms will be treated with personalized systemic chemotherapy. Primary endpoint is peritoneal recurrence-free survival at 3 years. An ancillary study will evaluate the correlation between surgical and pathological PCI, comparing their respective prognostic values. DISCUSSION: HIPEC with high-dose mytomicin-C, in patients with limited (PCI ≤ 20) and completely resected (CCS 0) peritoneal metastases, is assumed to reduce the expected risk of peritoneal recurrence from 50 to 30% at 3 years. TRIAL REGISTRATION: EudraCT number: 2019-004679-37; Clinicaltrials.gov: NCT05250648 (registration date 02/22/2022, ).

Influence of positive margins on tumour recurrence and overall survival after gastrectomy for gastric cancer.

BACKGROUND: Incidence of positive surgical margins after curative gastrectomy ranges from 1% to 20%. It has been suggested that positive surgical margin is an adverse prognosis factor, with a higher local recurrence and worse overall survival (OS). However, the management of these patients remains unclear. METHODS: A total of 267 patients who underwent gastrectomy with curative intent between January 2010 and December 2018 in our centre were enrolled in this study. Post-operative histological analysis revealed positive resection margins in 18 patients (8%). Clinicopathological features and outcome of patients undergoing gastrectomy with negative and positive margins were compared. RESULTS: Patients with positive margins were associated with higher American Joint Committee on Cancer (AJCC) stage, T stage, N stage, median number of positive nodes, diffuse Lauren type, whole stomach involved and poorly differentiated tumours. Local recurrence was described in 50% of cases with positive margins. The multivariate analysis demonstrated that the TNM stage was the only independent prognostic factor associated with recurrence. OS for positive margins at 1, 3 and 5 years was 75%, 57% and 26%, respectively. The median survival in patients with positive margins was 38.33 versus 81.17 months for R0 patients (p = 0.027). Multivariate analysis showed that age (hazard ratio [HR] 1.041, 95% confidence interval [CI] 1.02-1.07, sex (HR 2.00, 95% CI 1.22-3.30) and TNM stage (p < 0.001) were independent factors of OS. CONCLUSION: Positive resection margin was an indication of advanced and more aggressive disease rather than an independent prognosis factor for OS or recurrence in gastric cancer.

Training for the surgical management of postpartum hemorrhage: a multicenter survey of resident physicians.

BACKGROUND: To actively address maternal morbidity and mortality in Mexico, proficiency among obstetrics and gynecology (OBGYN) residents in the surgical management of postpartum hemorrhage (PPH) is a priority. However, the capacity of programs to provide this training is unknown. OBJECTIVE: The self-reported knowledge, education, and proficiency of common surgical techniques for the management of PPH among OBGYN residents in Mexico was evaluated. Educational resources, perceived barriers to acquiring skills, and clinical decision-making were explored. MATERIALS AND METHODS: In July of 2018, an anonymous electronic survey was sent to 86 residents at four hospitals throughout Mexico. Surgical techniques queried included uterine tamponade (UT), uterine compression sutures (UCS), uterine devascularization (UD), hypogastric artery ligation (HAL), and gravid hysterectomy (HT). Participants also answered case-based questions about a patient with PPH. RESULTS: The survey response rate was 59.3% (51/86). Seventy-nine percent of residents reported understanding the rationale and techniques for the surgical intervention of PPH. However, 43.9% reported limited ability to perform these procedures with autonomy. Eighty-six percent of residents reported exposure to these techniques while performing a rescue procedure during PPH and 49% reported learning these procedures while performing prophylactic techniques in patients without PPH. Only 25.5% had been exposed to simulation training. Lack of a training module for these skills in their curriculum was noted by 74.5%. The majority of the participants chose UCS, UD, HAL, and HT as the first, second, third, and fourth rescue procedures to perform for PPH, respectively. CONCLUSION: Most residents reported theoretical knowledge of surgical interventions for PPH, but their self-rated ability to independently perform such skills and a curriculum focused on PPH management was suboptimal.

Circulating Zinc and Copper Levels are Associated with Sperm Quality in Obese Men after Metabolic Surgery: A Pilot Study.

(1) Background: Inadequate levels of several trace elements and vitamins may impair spermatogenesis in men. Although weight loss after metabolic surgery normalizes male reproductive hormones, sperm quality seems to not improve. We hypothesized that circulating concentrations of zinc, copper and other trace elements and vitamins might be involved. (2) Methods: We studied 20 men submitted to metabolic surgery at baseline and after two years. Hormone profiles, serum trace elements and vitamins were studied together with sperm analysis. (3) Results: At follow-up, serum testosterone, follicle-stimulating hormone and inhibin B concentrations increased showing a beneficial hormonal response for spermatogenesis. Conversely, serum copper, zinc and ferritin showed a decline after surgery. In total, 33% of men showed zinc deficiency, 27% copper deficiency and 20% iron deficiency, among others. Sperm analysis showed that all revaluated patients had at least one abnormal parameter. Serum zinc concentrations showed a positive correlation with progressive motility (r = 0.577, p = 0.031), and serum ferritin a positive correlation with sperm volume (ρ = 0.535, p = 0.049). Serum copper showed a weak and near significant correlation with motility (r = 0.115, p = 0.051). (4) Conclusions: The lack of improvement in sperm quality in obese men after metabolic surgery may be related to nutrient malabsorption, especially zinc, copper and iron.

Fertility and Pregnancy Outcomes in Women with Polycystic Ovary Syndrome Following Bariatric Surgery.

CONTEXT: Restoration of ovulation is quite common in women with polycystic ovary syndrome (PCOS) after surgically induced weight loss. Whether or not this results in an improvement of PCOS-associated infertility is uncertain. OBJECTIVE: To study fertility and gestational outcomes in women with PCOS after bariatric surgery. DESIGN: Unicenter cohort study. SETTING: Academic hospital. PATIENTS: Two hundred and sixteen premenopausal women were screened for PCOS before bariatric surgery. Women were followed-up after the intervention until mid-2019 regardless of having or not PCOS. INTERVENTIONS: All participants underwent bariatric surgery from 2005 to 2015. MAIN OUTCOME MEASURES: Pregnancy and live birth rates in the PCOS and control groups. RESULTS: In women seeking fertility, pregnancy rates were 95.2% in PCOS and 76.9% in controls (P = 0.096) and live birth rates were 81.0% and 69.2%, respectively (P = 0.403). The time to achieve the first pregnancy after surgery was 34 ±â€…28 months in women with PCOS and 32 ±â€…25 months in controls. Albeit the mean birth weight was lower (P = 0.040) in newborns from women with PCOS (2763 ±â€…618 g) compared with those from controls (3155 ±â€…586 g), the number of newborns with low birth weight was similar in both groups (3 in the PCOS group and 1 in the controls, P = 0.137). Maternal (17.6% in PCOS and 22.2% in controls, P = 0.843) and neonatal (23.5% in PCOS and 14.8% in controls, P = 0.466) complications were rare, showing no differences between groups. CONCLUSIONS: Pregnancy and fertility rates in very obese women with PCOS after bariatric surgery were high, with few maternal and neonatal complications.

Impact of interval timing to surgery on tumor response after neoadjuvant treatment for gastric cancer.

INTRODUCTION: neoadjuvant chemotherapy (NACT) followed by radical surgery is the optimal approach for locally advanced gastric cancer (GC). Interval timing to surgery after NACT in GC is controversial. The aim of this study was to evaluate the impact of NACT interval time on tumor response and overall survival. MATERIAL AND METHODS: a retrospective analysis from a prospective database was performed at a single referral tertiary hospital, from January 2010 to October 2018. Patients were assigned to three groups according to the surgical interval time after NACT: < 4 weeks, 4-6 weeks and > 6 weeks. Univariate and multivariable analyses were performed in order to clarify the impact of NACT on post-neoadjuvant pathological complete response rate (ypCR), downstaging (DS) and overall survival (OS). RESULTS: of the 60 patients analyzed, 18 patients (30 %) had an interval time to surgery < 4 weeks, 26 (43.3 %) between 4-6 weeks and 16 (26.7 %) > 6 weeks. Two patients (3 %) had achieved ypCR and 37 patients (62 %) had achieved DS. There were no differences in DS rates among the interval time groups (p: 0.66). According to the multivariate analysis, only poorly differentiated carcinoma was significantly related to lower DS rates (p: 0.04). Cox regression analysis showed that the NACT interval time had no impact on OS. According to the multivariate analysis, > 25 lymph node harvested (HR: 0.35) and female sex (HR: 5.67) were OS independent predictors. CONCLUSIONS: the NACT interval time prior gastrectomy for locally advanced GC is not associated with ypCR or DS and has no impact on overall survival.

Changes in Soluble TWEAK Concentrations, but Not Those in Amyloid-ß(1-40), Are Associated with a Decrease in Carotid Intima-Media Thickness after Bariatric Surgery in Obese Women.

BACKGROUND/AIM: Soluble tumor necrosis factor-like weak inducer of apoptosis (sTWEAK) and amyloid-ß(1-40) (Aß40) emerged as markers of cardiovascular risk because of their actions in the endothelium and their role in atherosclerotic progression. The aim of this study was to analyze the association of these two factors with the decrease in carotid intima-media thickness (cIMT) after bariatric surgery in obese women. METHODS: We studied 60 severely obese women, of whom 20 were submitted to laparoscopic Roux-en-Y gastric bypass (RYGB), 20 to sleeve gastrectomy (SG), and 20 to lifestyle modification therapy. Circulating sTWEAK, Aß40, high-sensitivity C-reactive protein, plasminogen activator inhibitor type 1, insulin resistance (HOMA-IR), and cIMT were measured at baseline and after 1 year of follow-up. RESULTS: sTWEAK increased similarly after both surgical procedures, whereas the increase observed after lifestyle intervention did not reach statistical significance. Aß40 showed no differences between groups of women, nor did it change during follow-up. The decrease in cIMT at 12 months correlated with the decrease in body mass index (BMI) (r = 0.45; p < 0.001) and fasting insulin (r = 0.30; p = 0.038), and also with the increase in sTWEAK (r = -0.43; p = 0.002). Multivariate linear regression showed that only the changes in BMI (ß = 0.389; p = 0.005) and sTWEAK (ß = -0.358; p = 0.009) were associated with the decrease in cIMT (R2 = 0.313; F = 9.348; p < 0.001). CONCLUSIONS: One year after bariatric surgery, RYGB and SG induced a similar increase in circulating sTWEAK that occurred in parallel to the decrease observed in cIMT.

Sleeve Gastrectomy and Gastric Bypass Decrease the Carotid Intima-Media Thickness in Obese Men: Association with Weight Loss, Cardiovascular Risk Factors, and Circulating Testosterone.

BACKGROUND: Obesity surgery has shown to decrease the carotid intima-media thickness (IMT), but studies that compare different surgical techniques are scarce, especially in men. OBJECTIVE: To evaluate the changes in IMT in men after laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) and its association with circulating testosterone. SETTING: Academic Hospital. METHODS: We studied 40 men with severe obesity, of whom 20 were submitted to laparoscopic RYGB and 20 to SG. Twenty control men matched for age and degree of obesity were also included. Both patients and controls were evaluated at baseline and 6 months after surgery or conventional treatment with diet and exercise, respectively. RESULTS: The mean carotid IMT decreased after surgery irrespective of the surgical technique whereas no changes were observed in the control men submitted to conventional therapy (Wilks' λ = 0.745, P < 0.001 for the interaction, P < 0.001 for RYGB vs. controls, P = 0.001 for SG vs. controls, P = 0.999 for RYGB vs. SG). The decrease in the carotid IMT correlated with the increase in total testosterone (r = 0.428, P = 0.010) and lost BMI (r = 0.486, P < 0.001). Multivariate linear regression retained only the decrease in BMI (ß = 0.378, P = 0.003) after adjustment (R2 = 0.245, F = 9.229, P = 0.001). CONCLUSION: Both RYGB and SG decrease carotid IMT in men with obesity compared with conventional treatment with diet and exercise.

Assessment of short-term outcome with TiO2 mesh in laparoscopic repair of large paraesophageal hiatal hernias.

BACKGROUND: Laparoscopic large para-oesophageal hiatal hernia (LPHH) repair using mesh reinforcement significantly reduces postoperative recurrence rates compared to conventional suture repair, especially within short follow-up times. However, the ideal strategy for repairing LPHH remains disputable because no clear guidelines are given regarding indications, mesh type, shape or position. The aim of this study was to survey our short-term results of LPHH management with a biosynthetic monofilament polypropylene mesh coated with titanium dioxide to enhance biocompatibility (TiO2Mesh™). METHODS: A retrospective study was performed at Ramon y Cajal University Hospital, Spain from December 2014 to October 2018. Data were collected on 27 consecutive patients with extensive hiatal hernia defects greater than 5 cm for which a laparoscopic repair was performed by primary suture and additional reinforcement with a TiO2Mesh™. Study outcomes were investigated, including clinical and radiological recurrences, dysphagia and mesh-related drawbacks. RESULTS: Twenty-seven patients were included in our analysis; 10 patients were male, and 17 were female. The mean age was 73 years (range, 63-79 years). All operations were performed laparoscopically. The median postoperative hospital stay was 3 days. After a mean follow-up of 18 months (range, 8-29 months), only 3 patients developed clinical recurrence of reflux symptoms (11%), and 2 had radiological recurrences (7%). No mesh-related complications occurred. CONCLUSIONS: TiO2Mesh™ was found to be safe for laparoscopic repair of LPHH with a fairly low recurrence rate in this short-term study. Long-term studies conducted over a period of years with large sample sizes will be essential for confirming whether this mesh is suitable as a standard method of care with few drawbacks.

Lack of Improvement of Sperm Characteristics in Obese Males After Obesity Surgery Despite the Beneficial Changes Observed in Reproductive Hormones.

BACKGROUND: Even though obesity surgery normalizes circulating testosterone concentrations in males with obesity-associated secondary hypogonadism, its impact on spermatogenesis remains controversial. We aimed to evaluate sperm characteristics in obese men after bariatric surgery as well as changes in reproductive hormones. METHODS: Twenty severely obese men (body mass index (BMI) ≥ 35 kg/m2) were evaluated before and 2 years after bariatric surgery. The serum was assayed for insulin, leptin, kisspeptin, and inhibin B, among other hormones. Homeostasis model assessment of insulin resistance (HOMA-IR) was estimated. We used World Health Organization reference values for sperm analysis. RESULTS: After surgery, serum total testosterone, calculated free testosterone, inhibin B, and kisspeptin increased, whereas fasting insulin, HOMA-IR, and leptin concentrations decreased. Despite these improvements, sperm volume showed a small decrease after surgery, while the rest of sperm characteristics remained mostly unchanged. Abnormal sperm concentration persisted in 60% of the patients. CONCLUSIONS: Sperm characteristics may not improve after bariatric surgery despite the beneficial changes of reproductive hormones.

Outcomes of the Learning Curve in Our First 100 Consecutive Laparoscopic Gastrectomies.

INTRODUCTION: Laparoscopic surgery has been increasingly used for treatment of gastric cancer. However, standardization of this minimally invasive approach has not been reached yet because of its technical difficulties and the concern about oncological safety. The aim of the study was to analyze the outcomes of our learning curve in this complex surgical technique. MATERIAL AND METHODS: The first consecutive 100 cases of laparoscopic gastrectomy performed at our Hospital from November 2008 to February 2018 were enrolled. Patients were divided into 2 groups on the basis of the period during which they were operated upon. The training phase was considered between 2008 and 2014 (46 cases) and the more developed phase (MDP) between 2015 and 2018 (54 cases). Conversion, lymphadenectomy and retrieved lymph nodes, hospital length of stay, mean operative time, complications, reintervention, and mortality rates were compared between the 2 phases of learning curve. RESULTS: The number of retrieved lymph nodes was higher in the MDP (17±8.6 vs. 23.3±10.4; P=0.004). Furthermore, we have also found less complications (47.8% vs. 27.8%; P=0.038), a decreased reintervention rate (15.2% vs. 1.85%; P=0.023), and overall mortality (8.7% vs. 0%; P=0.003) in the MDP. There were no significant differences in conversion rate, mean operative time, and hospital length of stay between phases. CONCLUSIONS: Although we consider that our learning curve is not yet completed, as the average of monitored parameters have not reached a steady state, the improvement on surgical parameters and postoperative course in the last 2 years have showed that our results are close to the best results published in the literature.