Thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs comparing 2 reduced guidelines for pharmacological prophylaxis.

OBJECTIVE: To determine the thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs, comparing two guidelines of pharmacological prophylaxis recommended in the Guide to the Spanish Society for Obesity Surgery and the Obesity Section of the AEC. METHODS: Cohorts retrospective study from January-2010 to December-2019. Cases of vertical gastrectomy or gastric bypass were recorded, systematically applying multimodal rehabilitation protocols. Two reduced chemoprophylaxis regimens were analyzed, starting after surgery and maintained for 10 days; one with fondaparinux (Arixtra®) at a fixed dose of 2.5mg/day and the other with enoxaparin (Clexane®) with a single daily dose adjusted to BMI: 40mg/day for BMI of 35-40 and 60mg/day for BMI 40-60. RESULTS: 675 patients were included; 354 with Fondaparinux-Arixtra® during the period 2010-2015 and 321 with Enoxaparin-Clexane® during the period 2016-2019. There were no cases of DVT or clinical PE. However, the incidence of hemorrhage requiring reoperation, transfusion, or a decrease of more than 3g/dL hemoglobin was 4.7%, with no difference between groups. Mortality was nil. The average stay was 2.8 days and the outpatient follow-up was 100% during the first 6 months and 95% at 12 months. CONCLUSIONS: The combination of multimodal rehabilitation programs and mechanical and pharmacological thromboprophylaxis by experienced teams, reduces the risk of thromboembolic events and could justify reduced chemoprophylaxis regimens to decrease the risk of postoperative bleeding.

Riesgo trombótico y hemorrágico en cirugía bariátrica con programas de rehabilitación multimodal comparando 2 pautas reducidas de profilaxis farmacológica / Thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs comparing 2 reduced guidelines for pharmacological prophylaxis

Objetivo: Determinar el riesgo trombótico y hemorrágico en la cirugía bariátrica con programas de rehabilitación multimodal, comparando 2pautas de profilaxis farmacológica recomendadas en la Guía de la Sociedad Española de Cirugía de Obesidad y la Sección de Obesidad de la Asociación Española de Cirujanos. Métodos: Estudio retrospectivo de cohortes desde enero del 2010 hasta diciembre del 2019. Se registraron los casos de gastrectomía vertical o bypass gástrico, aplicando sistemáticamente protocolos de rehabilitación multimodal. Se analizaron 2 pautas reducidas de quimioprofilaxis, de inicio tras la cirugía y mantenida durante 10 días; uno con fondaparinux (Arixtra®) a dosis fija de 2,5mg/día y otro con enoxaparina (Clexane®) con dosis única diaria ajustada al IMC: 40mg/día para IMC de 35-40 y 60mg/día para IMC de 40-60.ResultadosSe incluyó a 675 pacientes; 354 con fondaparinux-Arixtra® durante el periodo 2010-2015 y 321 con enoxaparina-Clexane® durante el periodo 2016-2019. No hubo ningún caso de TVP o TEP clínico. No obstante, la incidencia de hemorragia con necesidad de una reoperación, trasfusión o con un descenso de más de 3g/dl de hemoglobina fue del 4,7%, sin diferencias entre los grupos. La mortalidad fue nula. La estancia media fue de 2,8 días y el seguimiento ambulatorio fue del 100% durante los primeros 6 meses y del 95% a los 12 meses. Conclusiones: La combinación de programas de rehabilitación multimodal y tromboprofilaxis mecánica y farmacológica por equipos experimentados, reduce el riesgo de eventos tromboembólicos y podría justificar las pautas reducidas de quimioprofilaxis para disminuir el riesgo de una hemorragia postoperatoria (AU)

Objective: to determine the thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs, comparing 2guidelines of pharmacological prophylaxis recommended in the Guide to the Spanish Society for Obesity Surgery and the Obesity Section of the AEC. Methods: Cohorts retrospective study from January-2010 to December-2019. Cases of vertical gastrectomy or gastric bypass were recorded, systematically applying multimodal rehabilitation protocols. Two reduced chemoprophylaxis regimens were analyzed, starting after surgery and maintained for 10 days; one with fondaparinux (Arixtra®) at a fixed dose of 2.5mg / day and the other with enoxaparin (Clexane®) with a single daily dose adjusted to BMI: 40mg / day for BMI of 35-40 and 60mg/day for BMI 40-60. Results: 675 patients were included; 354 with Fondaparinux-Arixtra® during the period 2010-2015 and 321 with Enoxaparin-Clexane® during the period 2016-2019. There were no cases of DVT or clinical PE. However, the incidence of hemorrhage requiring reoperation, transfusion, or a decrease of more than 3g / dL hemoglobin was 4.7%, with no difference between groups. Mortality was nil. The average stay was 2.8 days and the outpatient follow-up was 100% during the first 6 months and 95% at 12 months. Conclusions: The combination of multimodal rehabilitation programs and mechanical and pharmacological thromboprophylaxis by experienced teams, reduces the risk of thromboembolic events and could justify reduced chemoprophylaxis regimens to decrease the risk of postoperative bleeding.

Thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs comparing 2 reduced guidelines for pharmacological prophylaxis. / Riesgo trombótico y hemorrágico en cirugía bariátrica con programas de rehabilitación multimodal comparando 2 pautas reducidas de profilaxis farmacológica.

OBJECTIVE: to determine the thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs, comparing 2guidelines of pharmacological prophylaxis recommended in the Guide to the Spanish Society for Obesity Surgery and the Obesity Section of the AEC. METHODS: Cohorts retrospective study from January-2010 to December-2019. Cases of vertical gastrectomy or gastric bypass were recorded, systematically applying multimodal rehabilitation protocols. Two reduced chemoprophylaxis regimens were analyzed, starting after surgery and maintained for 10 days; one with fondaparinux (Arixtra®) at a fixed dose of 2.5mg / day and the other with enoxaparin (Clexane®) with a single daily dose adjusted to BMI: 40mg / day for BMI of 35-40 and 60mg/day for BMI 40-60. RESULTS: 675 patients were included; 354 with Fondaparinux-Arixtra® during the period 2010-2015 and 321 with Enoxaparin-Clexane® during the period 2016-2019. There were no cases of DVT or clinical PE. However, the incidence of hemorrhage requiring reoperation, transfusion, or a decrease of more than 3g / dL hemoglobin was 4.7%, with no difference between groups. Mortality was nil. The average stay was 2.8 days and the outpatient follow-up was 100% during the first 6 months and 95% at 12 months. CONCLUSIONS: The combination of multimodal rehabilitation programs and mechanical and pharmacological thromboprophylaxis by experienced teams, reduces the risk of thromboembolic events and could justify reduced chemoprophylaxis regimens to decrease the risk of postoperative bleeding.

Rehabilitación multimodal en cirugía bariátrica / Enhanced recovery after bariatric surgery

Los protocolos de rehabilitación multimodal o recuperación intensificada (PRI) son programas de cuidado del paciente basados en la evidencia científica y orientados a mejorar su recuperación postoperatoria. Abarcan todos los aspectos implicados en el cuidado del paciente y requieren un manejo multidisciplinar, en el que intervienen varios especialistas. La aplicación de estos protocolos se está extendiendo ampliamente por diferentes tipos de cirugías abdominales y extraabdominales, incluyendo la cirugía bariátrica. Facultativos de diferentes especialidades, con experiencia en el tratamiento de pacientes obesos mórbidos, han formado parte del grupo de trabajo que desarrolló este protocolo. Para evaluar la evidencia científica actualizada, se realizó una búsqueda bibliográfica sobre PRI en cirugía bariátrica en diferentes bases de datos, estableciendo los niveles de calidad de evidencia y el grado de recomendación según la metodología GRADE. Se agruparon las actuaciones incluidas en la matriz temporal en 3 etapas: preoperatorio, perioperatorio y postoperatorio

Enhanced recovery after surgery (ERAS) protocols are care programs based on scientific evidence and focused on postoperative recovery. They encompass all aspects of patient care and require multidisciplinary management, with the participation of diverse specialists. The implementation of these protocols is being extended to several abdominal and extra-abdominal surgeries, including bariatric approaches. Diverse specialists with wide experience in the management of morbidly obese patients have taken part in the working group that developed this protocol. A bibliographic search about ERAS in bariatric surgery in several databases was performed to evaluate the current scientific evidence, establishing evidence levels and recommendations according to the GRADE methodology. The items included in this protocol are separated into preoperative, perioperative and postoperative guidelines

Enhanced recovery after bariatric surgery. / Rehabilitación multimodal en cirugía bariátrica.

Enhanced recovery after surgery (ERAS) protocols are care programs based on scientific evidence and focused on postoperative recovery. They encompass all aspects of patient care and require multidisciplinary management, with the participation of diverse specialists. The implementation of these protocols is being extended to several abdominal and extra-abdominal surgeries, including bariatric approaches. Diverse specialists with wide experience in the management of morbidly obese patients have taken part in the working group that developed this protocol. A bibliographic search about ERAS in bariatric surgery in several databases was performed to evaluate the current scientific evidence, establishing evidence levels and recommendations according to the GRADE methodology. The items included in this protocol are separated into preoperative, perioperative and postoperative guidelines.

Prognostic factors of weight loss after sleeve gastrectomy: Multi centre study in Spain and Portugal. / Factores predictivos de pérdida ponderal tras la gastrectomía vertical. Estudio multicéntrico hispano-portugués.

INTRODUCTION: Sleeve gastrectomy (SG) has become a technique in its own right although a selective or global indication remains controversial. The weight loss data at 5 years are heterogeneous. The aim of the study is to identify possible prognostic factors of insufficient weight loss after SG. METHODS: A SG retrospective multicenter study of more than one year follow-up was performed. Failure is considered if EWL>50%. Univariate and multivariate study of Cox regression were performed to identify prognostic factors of failure of weight loss at 1, 2 and 3 years of follow up. RESULTS: A total of 1,565 patients treated in 29 hospitals are included. PSP per year: 70.58±24.7; 3 years 69.39±29.2; 5 years 68.46±23.1. Patients with EWL<50 (considered failure): 17.1% in the first year, 20.1% at 3 years, 20.8% at 5 years. Variables with influence on the weight loss failure in univariate analysis were: BMI>50kg/m2, age>50years, DM2, hypertension, OSA, heart disease, multiple comorbidities, distance to pylorus> 4cm, bougie>40F, treatment with antiplatelet agents. The reinforcement of the suture improved results. In multivariate study DM2 and BMI are independent factors of failure. CONCLUSION: The SG associates a satisfactory weight loss in 79% of patients in the first 5 years; however, some variables such as BMI>50, age>50, the presence of several comorbidities, more than 5cm section of the pylorus or bougie>40F can increase the risk of weight loss failure.

Factores predictivos de pérdida ponderal tras la gastrectomia vertical. Estudio multicéntrico hispano-portugués / Prognostic factors of weight loss after sleeve gastrectomy: Multicenter study in Spain and Portugal

INTRODUCCIÓN: La gastrectomía vertical (GV) se ha convertido en una técnica con entidad propia cuya indicación selectiva o global sigue siendo objeto de controversia. Los resultados ponderales a 5 años son heterogéneos. El objetivo del estudio es identificar posibles factores pronósticos de pérdida de peso insuficiente tras GV. MÉTODOS: Estudio multicéntrico retrospectivo de GV con seguimiento mayor de un año. Se considera fracaso si el PSP < 50%. Se realiza estudio univariado y multivariado de regresión de Cox para determinar los factores que influyen en el fracaso ponderal a 1, 2 y 3 años de seguimiento. RESULTADOS: Se incluye a 1.565 pacientes intervenidos en 29 hospitales. PSP al año: 70,58 ± 24,8; a los 3 años 69,39 ± 29,2; a los 5 años 68,46 ± 23,1. Pacientes con PSP <50 (considerado fracaso ponderal): 17,1% en el primer año, 20,1% a 3 años, 20,8% a 5 años. Las variables que mostraron relación con el fracaso ponderal en el estudio univariado fueron: IMC > 50 kg/m2, edad > 50 años, DM2, HTA, SAOS, cardiopatía, varias comorbilidades asociadas, distancia a píloro > 5 cm, bujía >40 F, tratamiento con antiagregantes. La sobresutura mejora los resultados. Las variables que mostraron ser factores predictivos de fracaso en el seguimiento fueron la DM2 y el IMC. CONCLUSIÓN: La GV asocia una pérdida de peso satisfactoria en el 79% de los pacientes en los primeros 5 años; sin embargo, algunas variables como el IMC > 50, la DM2, la edad > 50, la presencia de varias comorbilidades, la sección a más de 4cm del píloro o la bujía > 40 F pueden aumentar el riesgo de fracaso ponderal

INTRODUCTION: Sleeve gastrectomy (SG) has become a technique in its own right although a selective or global indication remains controversial. The weight loss data at 5 years are heterogeneous. The aim of the study is to identify possible prognostic factors of insufficient weight loss after SG. METHODS: A SG retrospective multicenter study of more than one year follow-up was performed. Failure is considered if EWL > 50%. Univariate and multivariate study of Cox regression were performed to identify prognostic factors of failure of weight loss at 1, 2 and 3 years of follow up. RESULTS: A total of 1,565 patients treated in 29 hospitals are included. PSP per year: 70.58 ± 24.7; 3 years 69.39 ± 29.2; 5 years 68.46 ± 23.1. Patients with EWL< 50 (considered failure): 17.1% in the first year, 20.1% at 3 years, 20.8% at 5 years. Variables with influence on the weight loss failure in univariate analysis were: BMI > 50 kg/m2, age > 50 years, DM2, hypertension, OSA, heart disease, multiple comorbidities, distance to pylorus> 4cm, bougie > 40F, treatment with antiplatelet agents. The reinforcement of the suture improved results. In multivariate study DM2 and BMI are independent factors of failure. CONCLUSION: The SG associates a satisfactory weight loss in 79% of patients in the first 5 years; however, some variables such as BMI > 50, age > 50, the presence of several comorbidities, more than 5 cm section of the pylorus or bougie > 40F can increase the risk of weight loss failure

Prognostic Factors for Morbimortality in Sleeve Gastrectomy. The Importance of the Learning Curve. A Spanish-Portuguese Multicenter Study.

BACKGROUND: Complications in sleeve gastrectomy (SG) can cast a shadow over the technique's good results and compromise its safety. The aim of this study is to identify risk factors for complications, and especially those that can potentially be modified to improve safety. METHODS: A retrospective multicenter cohort study was carried out, involving the participation of 29 hospitals. Data was collected on demographic variables, associated comorbidities, technical modifications, the surgeon's experience, and postoperative morbimortality. A multivariate logistic regression analysis was carried out on risk factors (RFs) for the complications of leak/fistula, hemoperitoneum, pneumonia, pulmonary embolism, and death. RESULTS: The following data were collected for 2882 patients: age, 43.85 ± 11.6. 32.9 % male; BMI 47.22 ± 8.79; 46.2 % hypertensive; 29.2 % diabetes2; 18.2 % smokers; bougie calibre ≥40 F 11.1 %; complications 11.7 % (2.8 % leaks, 2.7 % hemoperitoneum, 1.1 % pneumonia, 0.2 % pulmonary embolism); and death 0.6 %. RFs for complications were as follows: surgeon's experience < 20 patients, OR 1.72 (1.32-2.25); experience > 100 patients, OR 0.78 (0.69-0.87); DM2, OR1.48(1.12-1.95); probe > 40 F, OR 0.613 (0.429-0.876). Leak RFs were the following: smoking, OR1.93 (1.1-3.41); surgeon's experience < 20 patients, OR 2.4 (1.46-4.16); experience of 20-50 patients, OR 2.5 (1.3-4.86); experience >100 patients, OR 0.265 (0.11-0.63); distance to pylorus > 4 cm, OR 0.510 (0.29-0.91). RFs for death were as follows: smoking, OR 8.64 (2.63-28.34); DM2, OR 3.25 (1.1-9.99); distance to pylorus < 5 cm, OR 6.62 (1.63-27.02). CONCLUSIONS: The safety of SG may be compromised by nonmodifiable factors such as age >65, patient comorbidities (DM2, hypertension), and prior treatment with anticoagulants, as well as by modifiable factors such as smoking, bougie size <40 F, distance to the pylorus <4 cm, and the surgeon's experience (<50-100 cases).

Cirugía laparoscópica intragástrica: una opción en lesiones gástricas no resecables endoscópicamente / Intragastric laparoscopic surgery: An option for gastric lesions not resectable by endoscopy

Las lesiones mucosas y submucosas gástricas pueden abordarse por vía endoscópica, laparoscópica o por cirugía abierta. El tamaño, la localización y el tipo de crecimiento son determinantes a la hora de la elección de la técnica. El interés en la cirugía mínimamente invasiva ha llevado a desarrollar nuevos abordajes para suplir las dificultades de la laparoscopia tradicional, como puede ser el caso de la resección de lesiones próximas a la unión esofagogástrica no resecables endoscópicamente, donde la cirugía convencional puede producir estenosis o deformidades posoperatorias y aumento de la morbimortalidad. Presentamos nuestra experiencia en el abordaje de este tipo de lesiones mediante cirugía laparoscópica intragástrica en 3 pacientes consecutivos, con resultado satisfactorio. Este tipo de intervención supone un abordaje más en el arsenal de la cirugía mínimamente invasiva, que puede proporcionar ventajas frente a la cirugía tradicional

Gastric mucosal and submucosal lesions can be resected by endoscopy, laparoscopy or open surgery. Operative methods have varied depending on the location, endophytic growth and size of the lesion. Interest in minimally invasive surgery has increased and many surgeons are attempting laparoscopic approaches, especially in lesions of the stomach near the esophagogastric junction not amendable to endoscopic removal, because conventional surgery can produce stenosis and distort the postoperative anatomy, and increase morbimortality. We report our experience with laparoscopic intragastric surgery in 3 consecutive patients, with no complications. Laparoscopic intragastric surgery extends the surgeons’ armamentarium to resect complex gastric lesions, while offering patients the benefits of minimal access surgery

Intragastric laparoscopic surgery: An option for gastric lesions not resectable by endoscopy.

Gastric mucosal and submucosal lesions can be resected by endoscopy, laparoscopy or open surgery. Operative methods have varied depending on the location, endophytic growth and size of the lesion. Interest in minimally invasive surgery has increased and many surgeons are attempting laparoscopic approaches, especially in lesions of the stomach near the esophagogastric junction not amendable to endoscopic removal, because conventional surgery can produce stenosis and distort the postoperative anatomy, and increase morbimortality. We report our experience with laparoscopic intragastric surgery in 3 consecutive patients, with no complications. Laparoscopic intragastric surgery extends the surgeons' armamentarium to resect complex gastric lesions, while offering patients the benefits of minimal access surgery.

Preserved endothelial function in human obesity in the absence of insulin resistance.

BACKGROUND: Insulin resistance (IR) is frequently associated with endothelial dysfunction and has been proposed to play a major role in cardiovascular disease (CVD). On the other hand, obesity has long been related to IR and increased CVD. However it is not known if IR is a necessary condition for endothelial dysfunction in human obesity, allowing for preserved endothelial function in obese people when absent. Therefore, the purpose of the study was to assess the relationship between IR and endothelial dysfunction in human obesity and the mechanisms involved. METHODS: Twenty non-insulin resistant morbid obese (NIR-MO), 32 insulin resistant morbid obese (IR-MO), and 12 healthy subjects were included. Serum concentrations of glucose, insulin, interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), resistin and adiponectin were determined. IR was evaluated by HOMA-index. Endothelium-dependent relaxation to bradykinin (BK) in mesenteric microvessels was assessed in wire myograph. RESULTS: Serum IL-6, and TNF-α levels were elevated only in IR-MO patients while resistin was elevated and adiponectin reduced in all MO individuals. Mesenteric arteries from IR-MO, but not from NIR-MO subjects displayed blunted relaxation to BK. Vasodilatation was improved in IR-MO arteries by the superoxide scavenger, superoxide dismutase (SOD) or the mitochondrial-targeted SOD mimetic, mito-TEMPO. NADPH oxidase inhibitors (apocynin and VAS2870) and the nitric oxide synthase (NOS) cofactor, tetrahydrobiopterin failed to modify BK-induced vasodilatations. Superoxide generation was higher in vessels from IR-MO subjects and reduced by mito-TEMPO. Blockade of TNF-α with infliximab, but not inhibition of inducible NOS or cyclooxygenase, improved endothelial relaxation and decreased superoxide formation. CONCLUSIONS: Endothelial dysfunction is observed in human morbid obesity only when insulin resistance is present. Mechanisms involved include augmented mitochondrial superoxide generation, and increased systemic inflammation mediated by TNF-α. These findings may explain the different vascular risk of healthy vs unhealthy obesity.

Risk of gastrojejunal anastomotic stricture with multifilament and monofilament sutures after hand-sewn laparoscopic gastric bypass: a prospective cohort study.

BACKGROUND: Gastrojejunal (GJ) stricture is one of the most common late complications after laparoscopic Roux-en-Y gastric bypass (LRYGBP) with a hand-sewn anastomosis. The object of this study was to assess the risk of stricture for two types of resorbable suture (multifilament and monofilament) in a series of LRYGBPs performed by the same surgeon. DESIGN: Prospective cohort study. The study population consisted of a series of consecutive morbidly obese patients who underwent primary hand-sewn LRYGBP between March 2004 and May 2008 at the University Hospital in Getafe, Madrid, Spain. The study comprised 242 LRYGBPs with a four-layer continuous hand-sewn anastomosis using absorbable 3/0 gauge suture. The suture material was Ethicon Vicryl multifilament in the first 105 cases and Ethicon Monocryl monofilament in the following 137 cases. All patients were followed up monthly for the first 6 months and then every 6 months after that. RESULTS: The mean BMI was 46 +/- 4 for the multifilament cohort and 48 +/- 6 for the monofilament cohort with no significant difference between the two (p = 0.567). There were no anastomotic leaks, and no cases of marginal ulcer, abscess, abdominal sepsis, deep vein thrombosis, or pulmonary embolism were recorded. No cases required conversion to open surgery, and perioperative mortality was zero. In all, 11 cases of stricture (4.4%) were recorded, 10 in the multifilament suture cohort (9.5%), and only one in the monofilament suture cohort (0.7%; p = 0.001). The odds ratio was 14.3 (95% CI = 1.8-113.4). The mean outpatient follow-up period was 30 months (range = 6-42). CONCLUSIONS: Anastomotic GJ stricture is a common and well-known complication of laparoscopic gastric bypass for morbid obesity. Hand sewing with monofilament suture significantly lowered the frequency of this complication, and hence, monofilament should be the suture material of choice for this suturing technique.

[Gastric bypass and laparoscopic biliopancreatic diversion with manual anastomosis: results in 250 morbidly obese patients]. / Bypass gástrico y derivación biliopancreática laparoscópica efectuadas con anastomosis manual. Resultados en 250 pacientes obesos móbidos.

BACKGROUND: Gastrojejunostomy anastomosis after a gastric bypass or biliopancreatic diversion can be performed by staples or hand-sewn technique. The aim of this study is to analyze totally hand-sewn anastomosis by laparoscopy. METHODS: Morbid obese patients treated consecutively with a gastric bypass or biliopancreatic diversion in which the main anastomosis was performed with a totally hand-sewn gastrojejunostomy by laparoscopy at Hospital Universitario de Getafe from March-01 to November-07. RESULTS: 250 patients were included: 232 were gastric bypass and the remaining 18, biliopancreatic diversion. Mean BMI was 46 +/- 4. There was only one case of digestive bleeding for a marginal ulcer during immediate postoperative period (6th day). Later, there were 2 cases of complicated ulcers: due to bleeding and perforation. There were no anastomotic leaks from the hand-sewn gastrojejunostomy. A patient was re-operated on 48 hours after bypass due to a leak secondary to a thermal perforation at the lesser curvature. Radiological or endoscopic dilatation were required in 11 stenosis (4.4%) at gastrojejunostomy and none in the biliopancreatic diversion group. Mean surgical time for the anastomosis was 40+/-15 minutes. There were no deaths, sepsis, abdominal abscess, deep venous thrombosis or pulmonary embolism. Average hospital stay was 5.1+/-2.4 days. CONCLUSIONS: Even though most surgeons believe that staples anastomosis is easier, hand-sewn technique can be reproducible by surgeons with laparoscopic sutures experience. This technique has a longer operation time but continuous training provides advanced laparoscopic skills and significantly reduces operation time.

Bypass gástrico y derivación biliopancreática laparoscópica efectuadas con anastomosis manual. Resultados en 250 pacientes obesos móbidos / Gastric bypass and laparoscopic biliopancreatic diversion with manual anastomosis: results in 250 morbidly obese patients

Introducción. En cirugía bariátrica, la reconstrucción del tracto digestivo tras un bypass gástrico (BPG) o una derivación biliopancreática (DBP) se efectúa mediante una anastomosis gastroyeyunal mecánica o manual. El objetivo de este trabajo es analizar la anastomosis gastroyeyunal con sutura manual por laparoscopia. Pacientes y método. Serie de pacientes obesos mórbidos tratados con BPG o DBP con anastomosis gastroyeyunal por técnica manual vía laparoscópica en el Hospital Universitario de Getafe, desde marzo de 2001 a noviembre de 2007. Resultados. Se incluyó a 250 pacientes, de los que 232 fueron intervenidos por BPG y los 18 restantes, por DBP. El índice de masa corporal medio era 46 ± 4. Sólo se registró un caso de hemorragia digestiva (0,4%) por ulcus en la boca en el postoperatorio inmediato (sexto día). En el postoperatorio tardío hubo 2 casos de ulcus complicado (0,8%), 1 caso con hemorragia y 1 con perforación. No hubo ninguna fuga de la anastomosis. Una paciente fue reintervenida a las 48 h por una fuga secundaria a una perforación térmica en la curvatura menor del reservorio gástrico. Se registraron 11 (4,4%) estenosis, que precisaron dilatación radiológica o endoscópica; no hubo ninguna en los casos de derivación. El tiempo medio para la anastomosis fue de 40 ± 15 min. No hubo mortalidad ni se registró ningún caso de absceso, sepsis abdominal o tromboembolia. La estancia hospitalaria media fue de 5,1 ± 2,4 días. Conclusiones. Aunque la mayoría de los cirujanos consideran que la anastomosis mecánica es más sencilla, la técnica manual puede ser reproducida por cirujanos con experiencia en el manejo de suturas y nudos intracorpóreos. La técnica prolonga el tiempo quirúrgico, pero un entrenamiento continuo desarrolla la destreza del cirujano y acorta significativamente el tiempo operatorio The increased use of biomaterials for the repair of abdominal wall hernias has achieved a significant reduction in recurrences and consequently improved the quality of life of patients. However, the appearance of complications such as infection may require the implanted prosthetic material to be removed in a considerable number of patients. A possible treatment option in areas compromised by infection is the implant a biocompatible prosthetic material to generate, or induce the formation of a support tissue so that, in a second stage, the definitive repair of the parietal defect may be undertaken. This is the main goal of bioprostheses. These implants are composed of collagen of animal (usually porcine) or human origin. They should be acellular and fully biocompatible so that they induce a minimal foreign body reaction and immune response (AU)

Background. Gastrojejunostomy anastomosis after a gastric bypass or biliopancreatic diversion can be performed by staples or hand-sewn technique. The aim of this study is to analyze totally hand-sewn anastomosis by laparoscopy. Methods. Morbid obese patients treated consecutively with a gastric bypass or biliopancreatic diversion in which the main anastomosis was performed with a totally hand-sewn gastrojejunostomy by laparoscopy at Hospital Universitario de Getafe from March-01 to November-07. Results. 250 patients were included: 232 were gastric bypass and the remaining 18, biliopancreatic diversion. Mean BMI was 46 ± 4. There was only one case of digestive bleeding for a marginal ulcer during immediate postoperative period (6th day). Later, there were 2 cases of complicated ulcers: due to bleeding and perforation. There were no anastomotic leaks from the hand-sewn gastrojejunostomy. A patient was re-operated on 48 hours after bypass due to a leak secondary to a thermal perforation at the lesser curvature. Radiological or endoscopic dilatation were required in 11 stenosis (4.4%) at gastrojejunostomy and none in the biliopancreatic diversion group. Mean surgical time for the anastomosis was 40±15 minutes. There were no deaths, sepsis, abdominal abscess, deep venous thrombosis or pulmonary embolism. Average hospital stay was 5.1±2.4 days. Conclusions. Even though most surgeons believe that staples anastomosis is easier, hand-sewn technique can be reproducible by surgeons with laparoscopic sutures experience. This technique has a longer operation time but continuous training provides advanced laparoscopic skills and significantly reduces operation time The increased use of biomaterials for the repair of abdominal wall hernias has achieved a significant reduction in recurrences and consequently improved the quality of life of patients. However, the appearance of complications such as infection may require the implanted prosthetic material to be removed in a considerable number of patients. A possible treatment option in areas compromised by infection is the implant a biocompatible prosthetic material to generate, or induce the formation of a support tissue so that, in a second stage, the definitive repair of the parietal defect may be undertaken. This is the main goal of bioprostheses. These implants are composed of collagen of animal (usually porcine) or human origin. They should be acellular and fully biocompatible so that they induce a minimal foreign body reaction and immune response (AU)

Laparoscopic hand-sewn gastrojejunal anastomoses.

BACKGROUND: Reconstruction of the digestive tract during gastric bypass (RYGBP) or biliopancreatic diversion (BPD) involves a mechanical or a hand-sewn gastrojejunal anastomosis. The object of this paper is to assess laparoscopic hand-sewn gastrojejunal anastomoses. METHODS: A series of morbidly obese patients was treated with RYGBP or BPD with a laparoscopic hand-sewn gastrojejunal anastomosis at the Hospital Universitario de Getafe-Madrid (Spain) between March 2001 and November 2007. RESULTS: The series comprised 250 patients, with 232 RYGBPs and 18 BPDs performed. The mean BMI was 46 +/- 4. Only a single case of gastrointestinal hemorrhage (0.4%) was recorded, caused by a marginal ulcer in the early postoperative period (day 6). In the late postoperative period, there were two cases of ulcer (0.8%), one complicated by hemorrhage, the other by perforation. There was no anastomotic leak. One patient (0.4%) required reintervention after 48 h because of thermal perforation of the gastric pouch. There were 11 cases of stenosis (4.4%) requiring radiologically or endoscopically guided dilatation, none in the BPD patients. Mean anastomosis time was 40 +/- 15 min. No cases of mortality or abscess, abdominal sepsis, or thromboembolism were recorded. Mean hospital stay was 5.1 +/- 2.4 days. CONCLUSIONS: Laparoscopic hand-sewn anastomoses are safe and reproducible by surgeons experienced in internal suturing and knot-tying. The technique lengthens operating time, but constant training develops the surgeon's skills, significantly shortening operating time.

Usefulness of laboratory data in the management of right iliac fossa pain in adults.

PURPOSE: This study examined the usefulness of inflammatory markers in the management of patients with right iliac fossa pain. PATIENTS AND METHODS: A single site, prospective observational study was conducted from October 2001 to April 2003. Patients with right iliac fossa pain referred to the surgeon were included. Blood samples were obtained for C-reactive protein, leukocyte, and granulocyte analysis. Clinical, surgical, and histopathologic data were collected. Analysis of inflammatory parameters was performed with logistic regression and areas under the receiver operating characteristic curve were compared. RESULTS: C-reactive protein increased with the severity of appendicitis and predicted accurately perforation (r(2) = 0.613; P < 0.0005), showing the highest accuracy among inflammatory markers (areas under the receiver operating characteristics curve were 0.846, 0.753, and 0.685 for C-reactive protein, leukocyte and granulocytes, respectively; P < 0.001). Accuracy improved when C-reactive protein and leukocytes were combined; positive and negative predictive values were 93.2 percent and 92.3 percent, respectively. CONCLUSIONS: C-reactive protein is a helpful marker in the management of patients with right iliac fossa pain; the predictive value improves when combined with leukocyte count. A patient with normal C-reactive protein and leukocytes has a very low probability of appendicitis and should not undergo surgery.

Biopsia guiada por laparoscopia de tumoraciones intraabdominales no digestivas / Laparoscopic biopsy of non-digestive intra-abdominal masses

Introducción. La laparoscopia es un recurso diagnóstico de múltiples enfermedades que requieren biopsia de masas intraabdominales no abordables mediante punciones guiadas por imagen. Evita la morbimortalidad asociada a la laparotomía favoreciendo el tratamiento precoz de los procesos malignos. Pacientes y método. Análisis descriptivo, retrospectivo de los resultados de una serie de pacientes de nuestro hospital, que presentan nódulo intraabdominal de etiología desconocida biopsiados mediante cirugía laparoscópica desde enero de 2001 hasta mayo de 2006. Ninguno de los pacientes es candidato a punción percutánea guiada por imagen. Resultados. Realizamos 23 biopsias: 8 retroperitoneales (34,7%), 5 mesentéricas (21,7%), 5 en hilio hepático, 4 pelvianas y 1 en cadena de vena ilíaca y asociamos 5 biopsias complementarias. Se obtuvo un 100% de material suficiente para diagnóstico anatomopatológico. La duración media de la intervención fue de 71 min. El 61% tuvo un ingreso menor de 24 h. La estancia hospitalaria (mediana) fue de 1,5 días. Conclusiones. El abordaje laparoscópico permite una exposición y una revisión completa de la cavidad peritoneal. La biopsia laparoscópica es segura y efectiva con excelente recuperación del paciente permitiendo iniciar precozmente el tratamiento definitivo (AU)

Introduction. Laparoscopic surgery offers an alternative diagnostic technique in multiple diseases requiring biopsy of non-digestive intra-abdominal masses in which image-guided biopsy cannot be performed. Laparoscopic biopsy aims to reduce the surgical aggression and complications associated with laparotomy and favors the early treatment of malignancies. Patients and method. We performed a retrospective descriptive study of our results in a series of patients in our hospital with intra-abdominal masses of unknown etiology who underwent laparoscopic surgery between January 2001 and April 2006. None of the patients were candidates for image-guided percutaneous biopsy. Results. We carried out 23 biopsies: 8 retroperitoneal (34.7%), 5 mesenteric (21.7%), 5 hepatic, 4 pelvic, and 1 in the iliac chain, as well as 5 complementary biopsies. In all patients, sufficient material for histologic diagnosis was obtained. The mean operating time was 71 minutes. Length of hospital stay was less than 24 hours in 61% of the patients. The median length of hospital stay was 1.5 days. Conclusions. The laparoscopic approach allows complete visualization and examination of the entire peritoneal cavity. Laparoscopic biopsy is a safe and effective procedure with excellent patient recovery and allows early definitive treatment (AU)