Enhanced recovery after surgery in gastric resections. / Rehabilitación multimodal en la cirugía de resección gástrica.

INTRODUCTION: Enhanced recovery after surgery is a modality of perioperative management with the purpose of improving results and providing a faster recovery of patients. This kind of protocol has been applied frequently in colorectal surgery, presenting less available experience and evidence in gastric surgery. METHODS: According to the RICA guidelines published in 2015, a review of the bibliography and the consensus established in a multidisciplinary meeting in Zaragoza on the 9th of October 2015, we present a protocol that contains the basic procedures of fast-track for resective gastric surgery. RESULTS: The measures to be applied are divided in a preoperative, perioperative and postoperative stage. This document provides recommendations concerning the appropriate information, limited fasting and administration of carbohydrate drinks 2hours before surgery, specialized anesthetic strategies, minimal invasive surgery, no routine use of drainages and tubes, mobilization and early oral tolerance during the immediate postoperative period, as well as criteria for discharge. CONCLUSIONS: The application of a protocol of enhanced recovery after surgery in resective gastric surgery can improve and accelerate the functional recovery of our patients, requiring an appropriate multidisciplinary coordination, the evaluation of obtained results with the application of these measures and the investigation of controversial topics about which we currently have limited evidence.

[Prospective randomized trial of long-term results of inguinal hernia repair using autoadhesive mesh compared to classic Lichtenstein technique with sutures and polypropylene mesh]. / Estudio prospectivo y aleatorizado de los resultados a largo plazo de la hernioplastia inguinal con malla autoadhesiva frente a la técnica convencional con malla de polipropileno y sutura de fijación.

INTRODUCTION: The use of autoadhesive meshes with hooks that allow fixation without sutures is a therapeutic alternative to decrease recurrence and chronic pain after inguinal hernia repair. The aim of this study was to evaluate if this kind of mesh has any advantage in long term results in comparison with the classic Lichtenstein technique with sutures and polypropylene mesh. MATERIAL AND METHODS: We report a prospective and randomized study of patients who have been operated on for inguinal hernia between march of 2009 to march 2010, divided into 2 groups of 45 patients. In AutoAdhesive (AA) group, we included patients operated on with an autoadhesive mesh and in Classic Lichtenstein (CL) group we included cases with an inguinal hernioplasty with sutured polypropylene mesh. We evaluated time of inactivity, complications, recurrences and grade of pain after one year. RESULTS: The mean age was 60 years in AA group and 49 in LC group. There were more men than women and there were no differences in co-morbilities between groups. The mean size of hernia orifice was 3cm in both groups and 60% of the hernias were indirect. After one year, 77 patients were evaluated; 39 in LC group and 38 in AA group. 86,8% and 87,2% of them were asymptomatic. The mean time of recovery of daily activities was 15 days in both groups. There were neither recurrences nor severe chronic pain in the AA group. The mean of grade of pain was 0 (range:0-4) in AA group and 0 (range: 0-5) in LC group. In this group, there was one recurrence and one patient was taking analgesics for intense pain. No mortality nor other long term complications were found. CONCLUSION: The use of autoadhesive and parcial reabsorbible meshes in inguinal hernia repair has no effect on recovery of daily activities, postoperative pain and long term complications compared with hernioplasty with polypropylene mesh fixed with monofilament suture.

Association between use of enhanced recovery after surgery protocols and postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study.

INTRODUCTION: The effectiveness of the Enhanced Recovery After Surgery (ERAS) protocols in gastric cancer surgery remains controversial. METHODS: Multicentre prospective cohort study of adult patients undergoing surgery for gastric cancer. Adherence with 22 individual components of ERAS pathways were assessed in all patients, regardless of whether they were treated in a self-designed ERAS centre. Each centre had a three-month recruitment period between October 2019 and September 2020. The primary outcome was moderate-to-severe postoperative complications within 30 days after surgery. Secondary outcomes were overall postoperative complications, adherence to the ERAS pathway, 30 day-mortality and hospital length of stay (LOS). RESULTS: A total of 743 patients in 72 Spanish hospitals were included, 211 of them (28.4 %) from self-declared ERAS centres. A total of 245 patients (33 %) experienced postoperative complications, graded as moderate-to-severe complications in 172 patients (23.1 %). There were no differences in the incidence of moderate-to-severe complications (22.3% vs. 23.5%; OR, 0.92 (95% CI, 0.59 to 1.41); P = 0.068), or overall postoperative complications between the self-declared ERAS and non-ERAS groups (33.6% vs. 32.7%; OR, 1.05 (95 % CI, 0.70 to 1.56); P = 0.825). The overall rate of adherence to the ERAS pathway was 52% [IQR 45 to 60]. There were no differences in postoperative outcomes between higher (Q1, > 60 %) and lower (Q4, ≤ 45 %) ERAS adherence quartiles. CONCLUSIONS: Neither the partial application of perioperative ERAS measures nor treatment in self-designated ERAS centres improved postoperative outcomes in patients undergoing gastric surgery for cancer. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03865810.

[Metabolic changes after morbid obesity surgery using the duodenal switch technique. Long term follow-up]. / Alteraciones metabólicas tras cirugía de la obesidad mórbida mediante la técnica del cruce duodenal. Seguimiento a largo plazo.

INTRODUCTION: The duodenal switch (DS) technique is considered to be complex surgery with a series of metabolic complications due to its malabsorptive character. For these reasons, it has not been extensively used by bariatric surgeons. Despite this, we consider it to be a suitable technique for the grossly obese. PATIENTS AND METHODS: A retrospective study was performed on 110 patients with morbid obesity operated on using the DS technique and who were followed up for a minimum period of four years after surgery. We evaluated the weight loss, the outcomes of the comorbidities, and the metabolic complications. RESULTS: The loss of excess weight was greater than 50% in 75% of the patients after 12 months follow up. The comorbidities suffered by 68 patients (75.5%) were completely resolved. The most frequent metabolic complications were iron (Fe) deficiency and an increased parathyroid hormone (PTH). CONCLUSIONS: DS is a safe and effective technique for the treatment of morbid obesity, with good weight loss results, a high percentage of remission of the comorbidities, a similar morbidity and mortality to other techniques, and with correctable nutritional changes, and thus acceptable.

The Impact of Sleeve Gastrectomy on Gastroesophageal Reflux Disease in Patients with Morbid Obesity.

INTRODUCTION: The impact of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) has not been widely quantified, and the data in the literature remain controversial. MATERIALS AND METHODS: Candidates for LSG underwent barium swallow, esophageal manometry, ambulatory 24-h esophageal pH monitoring (APM), and gastric emptying scintigraphy before and after surgery (1 and 18 months). Symptoms were evaluated using a gastroesophageal reflux disease questionnaire (GERDq). Esophagogastroduodenoscopy was performed preoperatively in all patients and at 18 months postoperatively in patients who had suffered from preoperative esophagitis. RESULTS: Fifty-two patients were included in the study (64.4% women and 34.6% men) with a median age of 46 years (25-63 years) and BMI of 45.0 ± 5.6 kg/m2. The follow-up rates at 1 and 18 months were 82.7% and 80.8%. At 18 months, the percentage of weight loss (%TWL) was 33.6 ± 10.4% and the percentage of excess BMI loss (%EBMIL) was 77.6 ± 25%. Postoperatively, a significant increase in accelerated gastric emptying and impaired esophageal body motility occurred at 1 and 18 months. A significant worsening of all the values obtained at both 1 and 18 months postoperatively becomes evident when comparing the results of the APM. After surgery, 76.4% of patients had developed "de novo" GERD at 1 month and 41% at 18 months. No improvement was found in patients with symptomatic GERD. CONCLUSION: Based on the results of this study, LSG led to a considerable rate of postoperative "de novo" GERD. In addition, no improvement was found in patients with symptomatic GERD.

[Use of adhesive mesh in hernioplasty compared to the conventional technique. Results of a randomised prospective study]. / Utilización de mallas autoadhesivas en la hernioplastia frente a la técnica convencional. Resultados de un estudio prospectivo y aleatorizado.

INTRODUCTION: The use of meshes made with reabsorbable materials and structures that allow them to be fixed to the tissue without sutures, is considered as a therapeutic possibility in inguinal hernioplasty, reducing surgical times and supposedly improving pain and post-operative recovery. MATERIAL AND METHODS: A prospective randomised study of patients intervened for inguinal hernia between March 2009 and March 2010. Those patients subjected to hernia repair with a self-adhesive mesh (Parietene Progrip(®)) were placed in the in the SA (self-adhesive) group, and those subjected to hernia repair with a polypropylene mesh fixed with a monofilament suture in the CL (Classic Lichenstein) group. Complications and pain, using the visual analogue scale, were evaluated over 7 days. RESULTS: A total of 90 patients were divided into 2 groups of 45. The mean age was 60 y and 49 years, respectively, with the mean size of the hernia defect being 3cm, and approximately 60% were indirect hernias. The time of fixing the mesh and the overall surgery time was lower in the SA group than in the LC group: 56s versus 3min and 52s, and 17min and 45s versus 20min and 10s, respectively. There were no differences in hospital stay, complications or post-operative pain. CONCLUSION: The use of this type of mesh reduces the time of fixing the prosthesis and the total surgical time, with no effect on early post-operative pain or surgical complications compared to hernioplasty with a polypropylene mesh fixed with a monofilament suture.

Genetic screening for MC4R gene identifies three novel mutations associated with severe familiar obesity in a cohort of Spanish individuals.

MC4R gene is a hypothalamic satiety control mediator in which mutations cause a monogenic form of obesity. The aim of this study was to perform a genetic screening to identify variations in the entire region of MC4R gene. A total of 236 unrelated and severely obese patients (BMI ≥ 40 kg/m2) with Spanish ancestry and severe overweight familiar history have been enrolled into the study. Seven MC4R gene variants were identified in the heterozygous state in 21 patients. Coding variants p.Thr101Ile and p.Ala259Asp are new and variants p.Ser30Phe, p.Val103Ile and p.Ile251Leu were previously described. Two variants have been also observed in the promoter region of the MC4R gene; the c.-24G>A mutation, described for the first time, and the known c.-178A>C variant. Both in silico and family segregation analysis confirm the correlation between novel identified mutations in MC4R gene and obesity development. The correlation between the four variants (c.-24G>A, p.Thr101Ile, p.Ala259Asp and p.Ser30Phe) and the obesity phenotype, therefore, allows the conclusion that all of the four mutations cause a monogenic form of obesity.

Enhanced recovery after esophageal resection. / Rehabilitación multimodal en la cirugía resectiva del esófago.

ERAS is a multimodal perioperative care program which replaces traditional practices concerning analgesia, intravenous fluids, nutrition, mobilization as well as a number of other perioperative items, whose implementation is supported by evidence-based best practices. According to the RICA guidelines published in 2015, a review of the literature and the consensus established at a multidisciplinary meeting in 2015, we present a protocol that contains the basic procedures of an ERAS pathway for resective esophageal surgery. The measures involved in this ERAS pathway are structured into 3areas: preoperative, perioperative and postoperative. The consensus document integrates all the analyzed items in a unique time chart. ERAS programs in esophageal resection surgery can reduce postoperative morbidity, mortality, hospitalization and hospital costs.

[Relationship of oxidative stress and weight loss achieved in morbid obese patients by means of bariatric surgery using the duodenal switch technique]. / Relación del estrés oxidativo y la pérdida de peso obtenida en pacientes obesos mórbidos mediante cirugía bariátrica con la técnica del cruce duodenal.

INTRODUCTION: Oxidative stress (OS), which is overtly present in morbid obesity, is an indicator of a chronic inflammatory state associated to obesity and possibly related with the associated comorbidities, some of which represent an important risk factor for the occurrence of cardiovascular diseases, so that decreasing its intensity has become a treatment priority. MATERIALS AND METHODS: he have consecutively performed the duodenal crossing surgical technique in 28 patients suffering from morbid obesity, assessing the level of oxidative stress by the determination of the products of molecular oxidation and antioxidants before the surgery and throughout one year after the surgery. Weight evolution and the progression of the comorbidities already present were assessed. RESULTS: the mean age of the patients in this series was 43 ± 1 years and the mean BMI 50.3. 82% had associated comorbidities. After the surgery, all the patients progressively lost weight throughout the study period, with a parallel improvement of the comorbidities and a progressive decrease in OS values and improvement of the antioxidant systems, the OS values being similar to those of a normal population at the end of the study. CONCLUSION: The weight loss achieved allows improving the comorbidities and the oxidative stress values so that at the end of the study the results obtained are similar to those of a normal population.

Introducción: El estrés oxidativo, presente de forma evidente en los obesos mórbidos, es un indicador del estado inflamatorio crónico que representa la obesidad y posible nexo de unión con sus comorbilidades, algunas de las cuales son un importante factor de riesgo para el desarrollo de enfermedades cardiovasculares, por lo que la atenuación de su intensidad se ha convertido en un objetivo terapéutico. Material y método: Hemos intervenido de forma consecutiva, mediante la técnica quirúrgica del cruce duodenal, a 28 pacientes afectos de obesidad mórbida, realizando un estudio del estrés oxidativo presente en ellos mediante la determinación de productos de oxidación molecular y de antioxidantes, en el preoperatorio y a lo largo de un año tras la cirugía. Se ha controlado la evolución ponderal y la evolución de las comorbilidades presentes. Resultados: Los pacientes de la serie presentaron una media de edad de 43 ± 1 años y un IMC medio de 50,3. El 82% presentó comorbilidad asociada. Tras la cirugía todos los pacientes perdieron peso de forma progresiva a lo largo del periodo estudiado, con mejoría paralela de las comorbilidades y disminución progresiva de los valores del EO y mejoría de los sistemas antioxidantes, siendo los valores de EO al finalizar el estudio similares a los de la población normal. Conclusión: La pérdida de peso obtenida consigue una mejora de las comorbilidades y de los valores de estrés oxidativo de modo que al final del estudio los resultados obtenidos son similares a los de la población normal. Palabras clave: estrés oxidativo, obesidad, obesidad mórbida, cruce duodenal, pérdida de peso.

[Operating position in colorectal surgery. The importance of the basics]. / Posición operatoria en cirugía colorrectal. La importancia de lo básico.

Intra-operative positioning in colorectal surgery is very important from three points of view: the proper surgical approach and exposure, adequate anaesthetic requirements with maintenance of the airway, and the potential complications related to the position. In the present study, we analyse the indications, positioning, advantages and disadvantages of each operative position, their potential complications and how to avoid them. These complications can be of a diverse nature, the most common being injuries related to stretching or compression of peripheral nerves, followed by thromboembolic, haemodynamic, and ischaemic or compartmental syndromes related to ischaemia-reperfusion after a long time in the Trendelenburg position. Anaesthetists and surgeons should coordinate and take responsibility for the position of surgical patients.

[Donors yesterday and today: have the characteristics of liver donors changed over the last 15 years?]. / Donantes de ayer y de hoy: han cambiado las características de los donantes de hígado durante los últimos 15 años?

INTRODUCTION: The social, medical and demographic changes of our population and the increase in the number of patients on waiting lists have led to some changes in the selection criteria of organ donors. MATERIAL AND METHOD: A retrospective, descriptive and comparative study of the liver cadaveric donors features accepted in the Liver Transplant Unit in La Fe University Hospital of Valencia (Spain) in 2 different periods. We distributed the cases into 2 groups, including in group A the first 200 first donors (from January 1991 to June 1995) and in group B the last 200 donors (from February 2004 to December 2005). RESULTS: The number of donors increased from 18 during 1991 to 106 in 2006. In group A the mean age was 32.4 years, compared to 52.3 years in group B. In group A, the main cause of death was craneoencephalic traumatism and in group B cerebrovascular accidents. The mean time in the intensive care unit was longer in the second group with 67.2 hours. In group B, considerable atherosclerosis was reported in 17% of cadaveric donors and macroscopic liver steatosis in 29.5%, compared to 5 and 12%, respectively, in group A. CONCLUSIONS: Nowadays, cadaveric liver donors are older, suffer more chronic diseases, die due to cerbrovascular diseases, remain longer in intensive care units and the livers are macroscopically worse compared to donors accepted 15 years ago.