High rate of de novo esophagitis 5 years after sleeve gastrectomy: a prospective multicenter study in Spain.

BACKGROUND: Major concerns years after the sleeve gastrectomy (SG) include weight regain, development of hiatal hernia (HH) and gastroesophageal reflux disease, with esophagitis and Barrett's esophagus (BE). Both problems could be related, and the incidence of asymptomatic patients is troubling. OBJECTIVE: To study the incidence of reflux symptoms, esophagitis, BE, HH, and asymptomatic pathology and their relationship with weight regain in patients 5 years after undergoing SG at different bariatric centers in Spain. SETTING: Public and private hospitals with bariatric surgery units. METHODS: Prospective, multicenter, nonrandomized study involving 13 Spanish hospitals with a cumulative experience of 4,500 patients having undergone the SG procedure and patients who had been subjected to the procedure at least 5 years previously along with preoperative gastroscopy. The clinical history, preoperative gastroscopy, and technical details of the SG were recorded. A specific clinical questionnaire was given that recorded the intake volume, perception of satiety, and gastroesophageal reflux (GER) symptoms. Gastroscopy, pH-metry, and manometry studies were carried out, and the data were analyzed statistically. The study has been authorized by the official Spanish ethics committee CEI/CEIm Hospital Universitario Gran Canaria Dr Negrín (code 2019-216-1). RESULTS: One hundred and five patients who underwent SG and who had with at least 5 years of follow-up were included. All procedures were performed laparoscopically. The mean age of patients was 51.1 years, and 70.5% were women. The mean characteristics of the SG procedure were a 37.2F probe, at 4.6 cm from the pylorus, and a crura closure was performed in 5 cases. There were no major complications (Clavien-Dindo grade >3) or deaths. The average preoperative body mass index was 46.3 kg/m2, the minimum reached was 20.6 kg/m2, whereas the average after 5 years was of 34.5 kg/m2. GER, HH, and esophagitis symptoms went from 17.1%, 28.6%, and 5.7%, respectively, before the SG to 76%, 30.5%, and 31.4%, respectively, 5 years after the procedure. Symptoms persisted over the years in 37.1% of cases and presented de novo in 52.8% of cases. Fifty-three percent of manometries (n = 27, total 51) and 64% of pH-metries (n = 32, total 53; DeMeester average score was 65) were pathologic 5 years after the procedure. Concerning gastroscopies, 5 years after the procedure, HH was found in 33 patients (30.5% of total) and esophagitis in 32 patients (31.4% of total). Eighty patients (76%) had GER symptoms, and 25 patients (24%) were asymptomatic. Only 1 patient (.9%) developed BE. CONCLUSIONS: Our study has confirmed a high rate of both persistent and de novo esophagitis and hiatal hernia, many of which were asymptomatic, 5 years after SG had been performed. Weight regain and a striking increase in gastric capacity are risk factors indicative of esophagitis, even when patients are asymptomatic. We consider a control gastroscopy and the preventive use of proton pump inhibitors necessary in these cases regardless of symptoms. We recommend that a control gastroscopy should be performed in all cases regardless of symptoms 5 years after SG. Further studies are needed to validate these recommendations.

Electrocardiographic changes in rats undergoing thoracic surgery under combined parenteral anesthesia.

To compare two protocols of combined parenteral general anesthesia, the authors analyzed electrocardiographic changes in anesthetized rats undergoing left pneumonectomy. One group of rats was anesthetized with a combination of medetomidine and ketamine (group 1, n = 10), and the other was injected with diazepam and ketamine (group 2, n = 10). Investigators obtained two electrocardiograms from each rat, one before surgery (5 min after anesthesia) and one after surgery (60 min after anesthesia). Anesthetic induction was quick for all rats, though four rats in group 2 died before surgery. Mean cardiac frequency and R-wave amplitude were significantly lower in rats in group 1 than in rats in group 2. Rats in group 1 received injections of atipamezole about 60 min after surgery, which reversed the effects of medetomidine; these rats regained voluntary respiratory movement more quickly than did rats in group 2. Two additional rats in group 2 died during postsurgical recovery. These results suggest that for thoracic surgery in rats, medetomidine-ketamine is an appropriate anesthetic combination, may be safer than diazepam-ketamine and yields a shorter recovery time.

[Assessment of ischemia-reperfusion injury and early acute rejection in experimental lung transplantation after prolonged ischemia]. / Valoración de la lesión de isquemia-reperfusión y del rechazo agudo precoz en el trasplante pulmonar experimental con tiempo de isquemia prolongado.

OBJECTIVE: To assess ischemia-reperfusion injury and early acute rejection of the lung subjected to ischemia for 10 hours. MATERIAL AND METHODS: Fifteen of 30 Sprague-Dawley rats underwent transplantation of a left lung that had been subjected to ischemic times of 4 (n=5), 6 (n=5), or 10 hours (n=5). The cardiopulmonary block was removed from the donor, the left lung was dissected, and the transplant was carried out using the cuff technique. The cardiopulmonary block was extracted after 48 hours. We assessed postoperative progress, ischemia-reperfusion injury and acute rejection of the transplanted and contralateral lungs. Statistical probabilities were analyzed using the chi2 and Fisher exact tests. RESULTS: Clinical course was not worse after an ischemic time of 10 hours (P=.711). No significant differences were observed in histological markers of ischemia-reperfusion injury and acute rejection or in clinical course in relation to the different ischemic times; nor was clinical course related to the presence or severity of lesions or rejection. Similarly, acute rejection was unrelated to ischemia-reperfusion injury (P>.05). CONCLUSIONS: In this study, a prolonged ischemic time of 10 hours was not associated with ischemia-reperfusion injuries, with more severe acute rejection, or with a worse clinical course. Acute rejection was also unrelated to the presence or severity of ischemia-reperfusion injury.

Impact of number and site of lymph node invasion on survival of adenocarcinoma of esophagogastric junction.

Lymph node involvement in adenocarcinoma of the esophagogastric junction (EGJ) is similar to that of gastric cancer. The impact on survival of the number and site of lymph nodes involved in a subgroup of patients undergone surgery for adenocarcinoma of EGJ is reported. Sixty-four patients undergone transthoracic esophagectomy with two-field lymphadenectomy for adenocarcinoma of the EGJ were retrospectively assessed. Five-year survival according to AJCC gastric cancer nodal classification and central node invasion was evaluated. In N0 patients survival was assessed in relation to the number of lymph nodes removed. Five-year survival was 72% in N0, 46% in N1 and 0% in N2 and N3 group. Intergroup differences were statistically significant (P<0.05) except between N2 and N3 groups. Overall survival was different depending on the infiltration of distal or proximal site nodes, 23% vs. 58% (P<0.05); in N0 patients it was related to the number of lymph nodes removed (83% >15 vs. 57% <15, P<0.05). Classification of lymph node involvement in adenocarcinoma of the EGJ by gastric cancer criteria is adequate for prognostic purposes. The involvement of distal nodes in all cases and the removal of <15 nodes in N0 group resulted as independent negative predictive factors.