Clinical symptoms are correlated with gastrojejunal anastomosis complications only during the first year after laparoscopic Roux-en-Y gastric bypass / Los síntomas clínicos se relacionan con las complicaciones de la anastomosis gastroyeyunal solamente durante el primer año después del baipás gástrico laparoscópico

Introduction: after laparoscopic Roux-en-Y gastric bypass (LRYGBP) many patients complain of epigastric pain or food intolerance, leading to the performance of upper gastrointestinal (UGI) endoscopy. Objective: this study aims to assess which symptomatology as reported by LRYGBP patients during follow-up suggested correlation with pathological findings of endoscopy, and which factors might play a role, taking the timing of symptom presentation into account. Materials and methods: a retrospective cohort study was performed identifying LRYGBP patients presenting with food intolerance and/or epigastric pain who had undergone endoscopy. Primary outcomes were endoscopy findings, their association with patient characteristics, and timing of symptom presentation. Results: of the 514 patients complaining of epigastric pain and/or food intolerance, 81 (15.6 %) underwent endoscopy. A gastrojejunostomy complication was found in 58 % of cases. All patients who complained about food intolerance and epigastric pain presented pathological findings. The only preoperative factor associated with a gastrojejunostomy complication was being a smoker (p = 0.021). Time between surgery and endoscopy was also a predictive factor for endoscopic pathological findings (p = 0.007); in cases of epigastric pain, symptom onset during the first year (median: 10 months) was related to increased risk of gastrojejunal complications (p < 0.05). Conclusions: endoscopies performed within one year of surgery were significantly more likely to reveal pathological findings than endoscopies performed after the first postoperative year, especially in patients experiencing epigastric pain. (AU)

Introducción: tras un baipás gástrico laparoscópico en “Y de Roux” muchos pacientes refieren dolor epigástrico o intolerancia alimenticia, lo que motiva la realización de una endoscopia digestiva alta. Objetivos: el objetivo de este estudio es intentar establecer una relación entre la sintomatología referida por los pacientes sometidos a baipás gástrico con los hallazgos endoscópicos patológicos y conocer qué factores pueden estar implicados, considerando el momento de presentación. Material y métodos: estudio retrospectivo de cohortes, identificando a los pacientes sometidos a baipás gástrico laparoscópico que presentan dolor epigástrico o intolerancia alimenticia durante el seguimiento y a los que se realizó una endoscopia digestiva alta. El objetivo primario es relacionar los hallazgos endoscópicos con la sintomatología y el momento de aparición. Resultados: de los 514 pacientes que presentaban dolor epigástrico o intolerancia alimenticia, 81 (15,6 %) fueron sometidos a endoscopia digestiva alta. En un 58 % de los casos se encontraron complicaciones relacionadas con la gastroyeyunostomía. En todos los pacientes que presentaban simultáneamente dolor e intolerancia aparecieron hallazgos endoscópicos patológicos. El único factor preoperatorio relacionado con las complicaciones fue el hábito tabáquico (p = 0,021). El tiempo entre la cirugía y la realización de la endoscopia también fue un factor significativamente relacionado con los hallazgos endoscópicos (p = 0,007). En los casos de dolor epigástrico durante el primer año (media: 10 meses) existía un incremento del riesgo de aparición de complicaciones de la gastroyeyunostomía (p < 0,05). Conclusiones: las endoscopias realizadas durante el primer año postoperatorio tenían más probabilidades de presentar hallazgos patológicos, sobre todo en los pacientes afectos de dolor epigástrico. (AU)

Intraoperative Scintigraphy With Portable Gamma Camera for the Localization of Interaortocaval Paraganglioma.

ABSTRACT: A 15-year-old adolescent girl diagnosed of interaortocaval paraganglioma with a positive 123I-MIGB SPECT/CT and 1 unsuccessful prior surgery was operated on with the assistance of a handheld gamma camera. Once the lesion was located and removed, 2 images were taken, one of the surgical field (without 123I-MIGB uptake) and another of the tumor ex vivo (with high 123I-MIGB uptake), confirming that the lesion had been satisfactorily excised. This case highlights the use of a portable gamma camera as a useful tool to locate this rare tumor, with a SPECT/CT positive for 123I-MIGB and a difficult anatomical location suspected.

Clinical symptoms are correlated with gastrojejunal anastomosis complications only during the first year after laparoscopic Roux-en-Y gastric bypass.

INTRODUCTION: Introduction: after laparoscopic Roux-en-Y gastric bypass (LRYGBP) many patients complain of epigastric pain or food intolerance, leading to the performance of upper gastrointestinal (UGI) endoscopy. Objective: this study aims to assess which symptomatology as reported by LRYGBP patients during follow-up suggested correlation with pathological findings of endoscopy, and which factors might play a role, taking the timing of symptom presentation into account. Materials and methods: a retrospective cohort study was performed identifying LRYGBP patients presenting with food intolerance and/or epigastric pain who had undergone endoscopy. Primary outcomes were endoscopy findings, their association with patient characteristics, and timing of symptom presentation. Results: of the 514 patients complaining of epigastric pain and/or food intolerance, 81 (15.6 %) underwent endoscopy. A gastrojejunostomy complication was found in 58 % of cases. All patients who complained about food intolerance and epigastric pain presented pathological findings. The only preoperative factor associated with a gastrojejunostomy complication was being a smoker (p = 0.021). Time between surgery and endoscopy was also a predictive factor for endoscopic pathological findings (p = 0.007); in cases of epigastric pain, symptom onset during the first year (median: 10 months) was related to increased risk of gastrojejunal complications (p < 0.05). Conclusions: endoscopies performed within one year of surgery were significantly more likely to reveal pathological findings than endoscopies performed after the first postoperative year, especially in patients experiencing epigastric pain.

INTRODUCCIÓN: Introducción: tras un baipás gástrico laparoscópico en "Y de Roux" muchos pacientes refieren dolor epigástrico o intolerancia alimenticia, lo que motiva la realización de una endoscopia digestiva alta. Objetivos: el objetivo de este estudio es intentar establecer una relación entre la sintomatología referida por los pacientes sometidos a baipás gástrico con los hallazgos endoscópicos patológicos y conocer qué factores pueden estar implicados, considerando el momento de presentación. Material y métodos: estudio retrospectivo de cohortes, identificando a los pacientes sometidos a baipás gástrico laparoscópico que presentan dolor epigástrico o intolerancia alimenticia durante el seguimiento y a los que se realizó una endoscopia digestiva alta. El objetivo primario es relacionar los hallazgos endoscópicos con la sintomatología y el momento de aparición. Resultados: de los 514 pacientes que presentaban dolor epigástrico o intolerancia alimenticia, 81 (15,6 %) fueron sometidos a endoscopia digestiva alta. En un 58 % de los casos se encontraron complicaciones relacionadas con la gastroyeyunostomía. En todos los pacientes que presentaban simultáneamente dolor e intolerancia aparecieron hallazgos endoscópicos patológicos. El único factor preoperatorio relacionado con las complicaciones fue el hábito tabáquico (p = 0,021). El tiempo entre la cirugía y la realización de la endoscopia también fue un factor significativamente relacionado con los hallazgos endoscópicos (p = 0,007). En los casos de dolor epigástrico durante el primer año (media: 10 meses) existía un incremento del riesgo de aparición de complicaciones de la gastroyeyunostomía (p < 0,05). Conclusiones: las endoscopias realizadas durante el primer año postoperatorio tenían más probabilidades de presentar hallazgos patológicos, sobre todo en los pacientes afectos de dolor epigástrico.

Eficacia y eficiencia de un programa especial para la disminución de la lista de espera de cirugía bariátrica en un hospital terciario / Effectiveness and efficiency of a special program to reduce the bariatric surgery waiting list at a tertiary hospital

Introducción: La cirugía bariátrica es uno de los procedimientos quirúrgicos más realizados en España, sin embargo actualmente es la cirugía con mayor demora en la lista de espera quirúrgica (LEQ). Para disminuir la LEQ se pone en marcha un programa especial de autoconcertación, y se quiere valorar su utilidad, estudiando las repercusiones clínicas y económicas en una unidad de alto volumen de cirugía bariátrica. Métodos: Se realizó un estudio prospectivo de 3 meses comparando evolución, resultados y consumo de recursos perioperatorios de 45 pacientes operados de cirugía bariátrica, divididos en 2 grupos, pacientes operados en quirófano de forma estándar y pacientes operados en programación especial. Se tuvieron en cuenta factores epidemiológicos, asistenciales y económicos. Resultados: Se operaron 2 grupos homogéneos de pacientes, reduciendo con éxito la LEQ. La morbilidad fue similar en ambos grupos y el coste medio de las cirugías realizadas fue de 5.331,4euros, 5372,5±798,1euros para el grupo estándar y 5.290,3±685,1euros para el grupo de programación especial, sin diferencias significativas. Conclusiones: En centros hospitalarios donde se realiza alto volumen de cirugía bariátrica es factible incorporar programas especiales quirúrgicos que permiten la reducción en la demora de las listas de espera quirúrgica, manteniendo los criterios de calidad y sin suponer un mayor gasto al sistema sanitario. (AU)

Introduction: Bariatric surgery is one of the most common surgical practices in Spain. However, this procedure currently has longest delay on surgical waiting lists (SWL). We have developed a special surgical program that aims to reduce this waiting list and to assess the economic and clinical repercussions in a high-volume bariatric surgery unit. Methods: A three-month prospective study was carried out comparing outcomes, results and perioperative resources consumed for 45 patients who underwent bariatric surgery. The patients were divided into 2 groups: patients who underwent the standard procedure in the operating room, and patients treated in the special program. Epidemiological, healthcare and economic factors were taken into account. Results: Two homogeneous groups of patients were operated on, successfully reducing the SWL. Morbidity was similar in both groups and the average cost of the surgeries performed was €5,331.40; in the standard group, the cost was €5,372.50±€798.10, and the cost of the special program group was €5,290.30±€685.10, with no significant differences. Conclusions: In hospitals with a high volume of bariatric surgery, it is feasible to incorporate special surgical programs that are able to reduce surgical waiting lists, while maintaining quality criteria and without incurring a greater expense to the healthcare system. (AU)

Effectiveness and efficiency of a special program to reduce the bariatric surgery waiting list at a tertiary hospital. / Eficacia y eficiencia de un programa especial para la disminución de la lista de espera de cirugía bariátrica en un hospital terciario.

INTRODUCTION: Bariatric surgery is one of the most common surgical practices in Spain. However, this procedure currently has longest delay on surgical waiting lists (SWL). We have developed a special surgical program that aims to reduce this waiting list and to assess the economic and clinical repercussions in a high-volume bariatric surgery unit. METHODS: A three-month prospective study was carried out comparing outcomes, results and perioperative resources consumed for 45 patients who underwent bariatric surgery. The patients were divided into 2 groups: patients who underwent the standard procedure in the operating room, and patients treated in the special program. Epidemiological, healthcare and economic factors were taken into account. RESULTS: Two homogeneous groups of patients were operated on, successfully reducing the SWL. Morbidity was similar in both groups and the average cost of the surgeries performed was €5,331.40; in the standard group, the cost was €5,372.50±€798.10, and the cost of the special program group was €5,290.30±€685.10, with no significant differences. CONCLUSIONS: In hospitals with a high volume of bariatric surgery, it is feasible to incorporate special surgical programs that are able to reduce surgical waiting lists, while maintaining quality criteria and without incurring a greater expense to the healthcare system.

Shortening of the Common Channel as a Rescue Surgery After Gastric Bypass Failure.

BACKGROUND: After Roux-en-Y gastric bypass (RYGB), up to 30% failures in weight loss have been reported. Among multiple solutions available, we report our experience with shortening of the common channel (SCC) by performing a limb distalization of the alimentary or the biliopancreatic limb. SETTINGS: University Hospital. METHODS: We reviewed data from 23 patients that underwent limb distalization between 2001 and 2019 due to inadequate weight loss after an initial RYGB in our center. All patients who failed to achieve an excess weight loss reduction of > 50% or maintained a body mass index (BMI) above 35 kg/m2 were included. Multiple variables were analyzed during the follow-up at five time points: initial, after RYGB, before SCC, after SCC, and current. RESULTS: The mean BMI prior to the RYGB was 51.8 kg/m2, after RYGB was 37.6 kg/m2, before SCC was 43.6 kg/m2, after SCC was 36.1 kg/m2, and the final BMI was 36.3 kg/m2. No morbidity was seen after SCC. Long-term associated nutritional deficiencies were only identified in 3 patients which had iron deficiency and 1 patient with vitamin D deficiency. Patients with associated comorbidities significantly improved or were withdrawn from medications after the RYGB, with minor variations after SCC. CONCLUSIONS: Limb distalization with SCC is a safe and effective technique for patients who failed to achieve an adequate weight loss after RYGB. There is a slight increase in excess of weight loss after the SCC compared with RYGB. In addition, no further weight regain was documented.

Roux-en-Y Gastric Bypass as an Effective Bariatric Revisional Surgery after Restrictive Procedures.

INTRODUCTION: Revisional surgery must be considered when insufficient weight loss is attained or weight is subsequently regained. This study aimed to investigate the value of Roux-en-Y gastric bypass (RYGB) as a revisional procedure after restrictive surgery. MATERIALS AND METHODS: An observational, retrospective study including patients initially operated on for morbid obesity with restrictive techniques (vertical-banded gastroplasty [VBG], adjustable gastric band [AGB], and sleeve gastrectomy) and reoperated with RYGB in our centre between December 1994 and January 2019. Demographic and anthropometric data, associated comorbidities (diabetes mellitus type II, arterial hypertension, dyslipidaemia, and chronic obstructive pulmonary disease) and surgery-related data (approach, complications, and hospital stay) were evaluated at 5 different time points: initial (prior to first intervention), after the first surgical intervention, before the second intervention (gastric bypass), after the gastric bypass, and at present. RESULTS: A total of 63 patients were included. VBG was the most frequent initial procedure (n = 33). The mean age was 39 ± 9.52 years, and the average initial weight was 143.53 ± 28.6 kg. Weight loss was achieved in all groups, with a median excess weight loss of 58% after the first surgery and 40.3% after gastric bypass. In terms of weight loss, the best results after the second surgery were obtained when the first surgery was AGB, with statistically significant differences. CONCLUSIONS: RYGB is effective as a conversion procedure after a previous restrictive surgery, obtaining a significant reduction in weight and BMI. It has an acceptable morbidity rate and is more effective after an AGB.

Análisis de la pérdida ponderal a medio plazo después del bypass gastroyeyunal en Y de Roux y de la gastrectomía vertical: propuesta de gráficos de percentiles del porcentaje de peso total perdido para su uso en la práctica clínica diaria / Analysis of mid-term weight loss after Roux-en-Y gastric bypass and sleeve gastrectomy: Proposed percentile charts for total weight loss percentages to be used in daily clinical practice

Introducción: El objetivo de este trabajo es analizar la evolución ponderal de las principales técnicas quirúrgicas bariátricas (bypass gastroyeyunal en Y de Roux [BPGY] y gastrectomía vertical [GV]) realizadas en un conjunto representativo de centros nacionales españoles, con el fin de confeccionar unos gráficos de percentiles del porcentaje de pérdida total de peso perdido durante los 3 primeros años después de la cirugía. Métodos: Se realiza un estudio de cohortes longitudinal retrospectivo a partir de los datos aportados por 9 centros hospitalarios españoles. Se han analizado los datos ponderales tanto en porcentaje de pérdida total de peso perdido como en porcentaje de exceso de peso perdido correspondientes al BPGY (n = 1.887) y a la GV (n = 1.210). Resultados: El BPGY sigue siendo la técnica más frecuentemente realizada en nuestra muestra nacional. En ambas técnicas quirúrgicas, la pérdida de peso máxima se produce a los 18 meses de la cirugía. Ambas técnicas siguen la misma evolución ponderal, aunque los valores del porcentaje de pérdida total de peso perdido sean inferiores en el caso de la GV a los 36 meses (29,3 ± 10 vs. 33,6 ± 10). La edad y el género son determinantes en los resultados ponderales (mejores en paciente más jóvenes para ambas técnicas y mejores en mujeres para el BPGY). Conclusiones: Los gráficos de percentiles del porcentaje de peso total perdido después de la cirugía bariátrica representan una herramienta muy útil y un avance importante en la calidad asistencial para el seguimiento ponderal del paciente

Introduction: The aim of this study is to analyze weight evolution after the main bariatric surgical techniques (Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]) performed at a representative sample of Spanish hospitals in order to develop percentile charts for the percentage of total weight loss during the first 3 years after surgery. Methods: A retrospective longitudinal cohort study was conducted based on the data provided by 9 Spanish hospitals. Weight data were analyzed both in % total weight loss and % excess weight lost corresponding to the RYGB (n = 1,887) and SG (n = 1,210). Results: RYGB continues to be the most frequently performed technique in our sample. In both surgical techniques, maximum weight loss occurred 18 months after surgery. Both techniques followed the same weight evolution, although the % total weight loss values were lower in the case of the SG after 36 months (29.3 ± 10 vs. 33.6 ± 10). Age and gender are decisive in the weight results (better in younger patients for both techniques and better in women for RYGB). Conclusions: Percentile charts of % total weight loss after bariatric surgery represent a very useful tool and an important advance in the quality of patient management

Analysis of mid-term weight loss after Roux-en-Y gastric bypass and sleeve gastrectomy: Proposed percentile charts for total weight loss percentages to be used in daily clinical practice. / Análisis de la pérdida ponderal a medio plazo después del bypass gastroyeyunal en Y de Roux y de la gastrectomía vertical: propuesta de gráficos de percentiles del porcentaje de peso total perdido para su uso en la práctica clínica diaria.

INTRODUCTION: The aim of this study is to analyze weight evolution after the main bariatric surgical techniques (Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]) performed at a representative sample of Spanish hospitals in order to develop percentile charts for the percentage of total weight loss during the first 3 years after surgery. METHODS: A retrospective longitudinal cohort study was conducted based on the data provided by 9 Spanish hospitals. Weight data were analyzed both in % total weight loss and % excess weight lost corresponding to the RYGB (n=1,887) and SG (n=1,210). RESULTS: RYGB continues to be the most frequently performed technique in our sample. In both surgical techniques, maximum weight loss occurred 18 months after surgery. Both techniques followed the same weight evolution, although the % total weight loss values were lower in the case of the SG after 36 months (29.3±10 vs. 33.6±10). Age and gender are decisive in the weight results (better in younger patients for both techniques and better in women for RYGB). CONCLUSIONS: Percentile charts of % total weight loss after bariatric surgery represent a very useful tool and an important advance in the quality of patient management.

Cirugía bariátrica de conversión por fallo de la técnica inicial: 25 años de experiencia en una Unidad especializada de Cirugía de la Obesidad en España / Revisional bariatric surgery due to failure of the initial technique: 25 years of experience in a specialized Unit of Obesity Surgery in Spain

Objetivos: Valorar la eficacia de la cirugía de conversión en una unidad de cirugía bariátrica con 25 años de experiencia. Método: Estudio observacional retrospectivo de pacientes con obesidad tipo II o superior reintervenidos mediante cirugía de conversión por reganancia de peso, índice de masa corporal (IMC) residual > 35 kg/m2 o pérdida < 50% del exceso de peso. Se analizaron los datos demográficos y antropométricos, las comorbilidades y los datos perioperatorios en 5 periodos de tiempo: inicial, post-cirugía1, pre-cirugía2, post-cirugía2 y actualidad. Resultados: Se incluyeron un total de 112 pacientes con una media de edad de 40,2 años intervenidos inicialmente mediante gastroplastia vertical anillada (GVA) (32,1%), banda gástrica ajustable (BGA) (23,2%), bypass gástrico en Y de Roux (BGYR) (21,4%) y gastrectomía vertical (GV) (23,2%). Las técnicas de conversión, realizadas tras una mediana de 70 meses, incluyeron: BGYR (58,9%), GV (1,8%), bypass gástrico de una anastomosis (BAGUA) (11,6%), acortamiento de asa común (AAC) (24,1%) y derivación bilio-pancreática (DBP) (3,6%). Hubo una reducción del peso inicial de 144,2 ± 30,3 a 101,5 ± 21,8 kg tras la cirugía-1 y de 115,6 ± 24,0 a 91,5 ± 19,0 kg tras la cirugía-2. El peso en la actualidad es de 94,7 ± 16,4 kg tras una mediana de seguimiento de 27,5meses. Un grado de reducción similar ocurrió con el IMC. La mejoría de las comorbilidades se produjo sobre todo tras la primera intervención. Conclusiones: La cirugía de conversión provoca una reducción de peso que no supera a la pérdida alcanzada tras la primera cirugía, pero a diferencia de esta, logra estabilizar el peso a lo largo del tiempo. La tasa de morbilidad perioperatoria es aceptable y justificaría su aplicación, a pesar de que el impacto en las comorbilidades sea limitado

Objectives: To evaluate the effectiveness of conversion surgery in a bariatric surgery unit with 25 years of experience. Method: Retrospective observational study of patients with typeII obesity or higher who were reoperated by means of conversion surgery due to weight regain, residual body mass index (BMI) > 35 kg/m2 or <5 0% of excess weight loss. The demographic and anthropometric data, comorbidities and perioperative data were analyzed in 5 periods of time: initial, post-surgery1, pre-surgery2, post-surgery2 and current. Results: A total of 112 patients were included, with a mean age of 40.2 years, who initially underwent vertical banded gastroplasty (VBG) (32.1%), gastric banding (GB) (23.2%), Roux-en-Y gastric bypass (RYGB) (21.4%) and sleeve gastrectomy (SG) (23.2%). The conversion techniques, with a median time between the two surgeries of 70months, included: RYGB, SG, one-anastomosis gastric bypass (OAGB), shortening of the common loop (SCL) and biliopancreatic diversion (BPD). There was a reduction of the initial weight from 144.2 ± 30.3 to 101.5 ± 21.8 kg after surgery-1; from 115.6 ± 24.0 to 91.5 ± 19.0 kg after surgery-2. The weight at present is 94.7 ± 16.4 kg, with a median follow-up of 27.5 months. Similar results were seen with the BMI. The improvement of comorbidities mainly occurred after the first intervention. Conclusions: Conversion surgery causes a weight reduction that does not exceed the loss achieved after the first surgery; however, it does manage to stabilize weight over time. The perioperative morbidity rate is acceptable and would justify its application, despite the limited impact on comorbidities

Revisional bariatric surgery due to failure of the initial technique: 25 years of experience in a specialized Unit of Obesity Surgery in Spain. / Cirugía bariátrica de conversión por fallo de la técnica inicial: 25 años de experiencia en una Unidad especializada de Cirugía de la Obesidad en España.

OBJECTIVES: To evaluate the effectiveness of conversion surgery in a bariatric surgery unit with 25years of experience. METHOD: Retrospective observational study of patients with typeII obesity or higher who were reoperated by means of conversion surgery due to weight regain, residual body mass index (BMI)>35kg/m2 or <50% of excess weight loss. The demographic and anthropometric data, comorbidities and perioperative data were analyzed in 5 periods of time: initial, post-surgery1, pre-surgery2, post-surgery2 and current. RESULTS: A total of 112 patients were included, with a mean age of 40.2years, who initially underwent vertical banded gastroplasty (VBG) (32.1%), gastric banding (GB) (23.2%), Roux-en-Y gastric bypass (RYGB) (21.4%) and sleeve gastrectomy (SG) (23.2%). The conversion techniques, with a median time between the two surgeries of 70months, included: RYGB, SG, one-anastomosis gastric bypass (OAGB), shortening of the common loop (SCL) and biliopancreatic diversion (BPD). There was a reduction of the initial weight from 144.2±30.3 to 101.5±21.8kg after surgery-1; from 115.6±24.0 to 91.5±19.0kg after surgery-2. The weight at present is 94.7±16.4kg, with a median follow-up of 27.5months. Similar results were seen with the BMI. The improvement of comorbidities mainly occurred after the first intervention. CONCLUSIONS: Conversion surgery causes a weight reduction that does not exceed the loss achieved after the first surgery; however, it does manage to stabilize weight over time. The perioperative morbidity rate is acceptable and would justify its application, despite the limited impact on comorbidities.