Sleeve gastrectomy as a bridge to maternity in a patient with obesity, infertility and tetraplegia. A case report.

Traumatic spinal cord injury (SCI) is a major cause of severe and permanent disability in young adults. Overweight and obesity are commonly observed among patients affected with SCI, with reports of a prevalence of over 60 and 30% respectively. Case report: A 34 year-old woman suffering from tetraplegia after sustaining a traumatic injury to C5-C6 at age 23 as a result of a motor vehicle accident was presented to our hospital's multidisciplinary bariatric team due to class II obesity. At the time of presentation to the team, eleven years after the accident, her BMI was calculated to be 39 Kg/m2 (weight 97 kg, height 1.57 meters). She was diagnosed with infertility while seeking pregnancy, and referred to our bariatric unit for weight loss. In addition, she had overcome the physical limitations of her injury, had a regular job and was engaged in regular physical activities such as swimming. In May 2017, she underwent laparoscopic sleeve gastrectomy (LSG) without complications and was discharged on postoperative day 2. 17 months following LSG, with a normal BMI, she became naturally pregnant. She had emergency cesarean at 35 weeks due to pneumonia but both patient and child recovered without sequelae. Currently, 4 years after surgery she maintains 37.11% total weight loss (weight 61 kg). She reports having a better quality of life with fewer medical intercurrencies. Conclusions: Patients with SCI and obesity, particularly women seeking to conceive, may be benefited by being referred to bariatric teams for assessment and treatment to improve results associated with sustained weight reduction.

ESTUDIO METAGENÓMICO DE LA MICROBIOTA INTESTINAL EN PACIENTES CON OBESIDAD MÓRBIDA SOMETIDOS A CIRUGÍA BARIÁTRICA / METAGENOMIC STUDY OF THE INTESTINAL MICROBIOTA IN PATIENTS WITH MORBID OBESITY UNDERGOING BARIATRIC SURGERY

Introducción: La cirugía bariátrica (CB) es un tratamiento quirúrgico de la obesidad, cuyo objetivo es lograr el descenso de peso, de masa grasa y alcanzar un impacto metabólico a largo plazo. Se ha observado que ciertos pacientes no responden tan efectivamente a la cirugía, teniendo un descenso de peso inefectivo o recuperando peso tardíamente, y los mecanismos por lo que esto ocurre aún no están bien caracterizados. La microbiota intestinal tiene un rol esencial en varios de los procesos metabólicos asociados a la obesidad. El objetivo de este estudio fue caracterizar el metagenoma intestinal de pacientes candidatos para CB y otros que fueron operados, así como también evaluar las diferencias entre aquellos pacientes que tuvieron un resultado exitoso de la CB y los que no. Material y método: Se extrajo el ADN de 200 mg de heces de pacientes que cumplen criterios de CB, divididos en 3 grupos, basal (preoperatorio), 12 meses y más de 24 meses postoperatorios, con el fin de estudiar y comparar el perfil taxonómico de las comunidades bacterianas de la microbiota intestinal. Resultados: Mientras que la riqueza específica de los grupos de estudio no presentó diferencias significativas, la diversidad beta, que considera las abundancias relativas de los miembros de las comunidades bacterianas estudiadas, evidenció una composición global significativamente diferente entre los grupos de estudio. Sin embargo, nuestro análisis no identificó taxones específicos que pudieran dar explicación a la distinta evolución postoperatoria de los pacientes. Discusión: En la estructura de las comunidades microbianas, se observaron diferencias numéricas entre los grupos en cuanto a la riqueza y abundancia de taxones así como la comparación cuanti y cualitativa. Esta última presentó significativa disimilitud. Los resultados muestran que la principal diferencia entre los grupos de estudio se basó en la abundancia relativa de los gérmenes, cuyo estudio integral podría revelar patrones más consistentes y significativos vinculados a los mecanismos de respuesta terapéutica en sujetos sometidos a CB

Introduction: Bariatric surgery (BS) is a surgical treatment of obesity, which aims to achieve weight loss, fat mass loss and achieve a long-term metabolic impact. It has been observed that certain patients do not respond as effectively to surgery, having ineffective weight loss or regaining weight late, and the mechanisms by which this occurs are not yet well characterized. The intestinal microbiota plays an essential role in several of the metabolic processes associated with obesity. The objective of our study was to characterize the intestinal metagenome of candidate patients for CB and others who underwent surgery, as well as evaluate the differences between those patients who had a successful outcome from CB and those who did not. Material and method: DNA was extracted from 200 mg of feces from patients who met the criteria for surgical indication divided into 3 groups, baseline (preoperative), 12 months and more than 24 months postoperatively, in order to analyze and compare the taxonomic profile of the bacterial communities of the intestinal microbiota. Results: While the specific richness of the study groups did not present significant differences, beta diversity, which considers the relative abundances of the members of the bacterial communities studied, showed a significantly different global composition between the study groups. Nevertheless, our study did not identify specific taxa that could explain the different postoperative evolution of the patients. Discussion: In the structure of the microbial communities, numerical differences were observed between the groups in terms of the richness and abundance of taxa as well as the quantitative and qualitative comparison. The latter evidenced significant dissimilarity. The results show that the main difference between the study groups was based on the relative abundance of the germs, whose comprehensive study could reveal more consistent and significant patterns linked to the therapeutic response mechanisms in subjects subjected to CB. Bariatric surgery (BS) is a surgical treatment of obesity, whose objective is to achieve weight loss, fat mass and achieve a longterm metabolic impact. However, it has been observed that certain patients do not respond as effectively to surgery, having ineffective weight loss or late weight regain, and the mechanisms by which this occurs are not yet well characterized. The intestinal microbiota plays an essential role in several of the metabolic processes associated with obesity. The aim of this study was to characterize the intestinal metagenome of patients who will and who underwent BS, as well as to assess the differences between those patients who had a successful BS outcome and those who did not. Our results did not identify specific taxa that could explain the different evolution of the patients. While the specific richness of the study groups did not present significant differences, the beta diversity, which considers the relative abundances of the members of the studied bacterial communities, showed a significantly different global composition between the study groups

Malrotación intestinal en el adulto: cirugía de Ladd laparoscópica / Intestinal Malrotation in Adults: laparoscopic Ladd's Surgery

Las malrotaciones por bandas de Ladd son un subtipo de anormalidades de la embriogénesis consistentes en prolongaciones fibrosas, producto de una fijación anómala del mesenterio. Se extienden desde el ciego mal rotado hacia el retroperitoneo, pudiendo producir compresión extrínseca del duodeno. En el 90% de los casos la presentación clínica tiene lugar dentro del primer año de vida como un cuadro agudo, en forma de oclusión duodenal o vólvulo de intestino delgado con la consecuente isquemia de este o hernia interna. En la edad adulta, las formas de presentación son menos específicas. Los métodos de referencia ("gold standard") utilizados para el diagnóstico son la seriada gastroduodenal y la tomografía computarizada. El tratamiento quirúrgico consiste en la cirugía de Ladd, cuyo abordaje convencional fue descripto en 1936 por William Ladd. Presentamos el caso de un paciente adulto con un cuadro oclusivo, causado por dicha anomalía, diagnosticado de forma oportuna y resuelto de manera segura por vía laparoscópica. (AU)

Ladd's band malrotations are a subtype of abnormalities of embryogenesis consisting of fibrous extensions, product of abnormal fixation of the mesentery, that goes from the poorly rotated cecum towards the retroperitoneum, which can cause extrinsic compression of the duodenum. In 90% of cases, the clinical presentation takes place within the first year of life, as an acute condition, like duodenal occlusion or small bowel volvulus with its consequent ischemia or internal hernia. In adulthood, the forms of presentation are less specific. The gold standard methods used for diagnosis are gastroduodenal series and computed tomography. Surgical treatment consists of Ladd's surgery, whose conventional approach was described in 1936 by William Ladd. We present ta case of an adult patient with an occlusive presentation, given by this anomaly, diagnosed in a timely manner and safely resolved by laparoscopic approach. (AU)

Teaching strategies and outcomes in 3 different times of the COVID-19 pandemic through a dynamic assessment of medical skills and wellness of surgical trainees.

BACKGROUND: The coronavirus disease 2019 pandemic had a substantial impact on surgical training programs. This study describes the teaching strategies and outcomes in 3 different times of the coronavirus disease 2019 pandemic through a dynamic assessment of medical skills and well-being of trainees. METHODS: Three surveys were administered during 2020 to general surgery residents and fellows in a university hospital in Argentina. Perceptions on the impact of coronavirus disease 2019 were described. The stress rate and risk factors were analyzed. RESULTS: The study included 124 answers. In total, 59% were men, 82% of trainees reported concerns about the loss of surgical skills in early phase 1. Time spent with academic activities increased in 94.5% of the cases. Owing to the prompt implementation of changes, by the end of 2020, 73% participated in a greater number of procedures (P = .003); personal protective equipment use related problems dropped from 40% to 14% (P = .031), and the lack of adequate spaces where trainees could express reduced from 28% to zero. Half of the trainees felt stressed, and 18% required psychological assistance; reporting problems with personal protective equipment use was identified as a risk factor (P = .012). CONCLUSION: Assessing trainees' perceptions at 3 different times of the coronavirus disease 2019 pandemic enabled the implementation of dynamic changes. The negative impact on surgical training was partially offset by the optimal use of virtual learning. Half of them felt stressed, identifying problems in the use of personal protective equipment as a predisposing factor.

Percepciones de los médicos en formación en Cirugía General en la fase inicial de la pandemia por COVID-19 / Perceptions of general surgeons in training in the initial phase of COVID-19 pandemic

RESUMEN Objetivo: describir las percepciones de los cirujanos en formación durante la fase inicial de la pandemia por COVID-19. Material y métodos: se realizó el análisis transversal de una encuesta de 51 preguntas a médicos en formación de un Servicio de Cirugía General en un hospital de la Argentina. Se abarcaron 5 ámbitos: institucional, asistencial, académico, doméstico y emocional. Resultados: en total 55 médicos completaron la encuesta (91,7%): 35 residentes y 20 becarios de perfeccionamiento; 56,4% eran hombres. El 98,1% consideró suficiente la información brindada por el hospital y el servicio sobre las medidas tomadas con respecto al COVID-19. Si bien el 98,1% consideró satisfactorios los instructivos sobre los equipos de protección personal, el 38% informó inconvenientes en su utilización. El 92,5% de los residentes estuvo de acuerdo con el esquema de guardias implementado. El 94,5% incrementó el tiempo dedicado a actividades académicas. El 75% consideró útil el cronograma de clases virtuales implementado. El 72,7% de los encuestados consideró que contaba con espacios donde manifestar sus preocupaciones. El 60% consideró adecuada la supervisión. El 81,81% manifestó preocupación por perder habilidad manual. El 53% dijo sentirse frustrado y el 54% manifestó temor de contagiar a su familia/pareja. Conclusión: conocer las percepciones de los cirujanos en formación en la fase inicial de la pandemia por COVID-19 permitió detectar oportunidades de mejora e incorporar nuevas estrategias educativas para afrontar las fases siguientes, asegurando el aprendizaje y priorizando su bienestar físico y psicosocial.

ABSTRACT Objective: The aim of this study is to describe the perceptions of surgeons in training during the initial phase of the COVID-19 pandemic. Material and methods: A 51-question survey was conducted among physicians in training from a department of surgery in an Argentine hospital. Five domains were explored: institutional, healthcare, academic, domestic and emotional. Results: The survey was completed by 55 physicians (91.7%): 35 residents and 20 fellows. Among the respondents, 98.1% considered the information provided by the hospital and the department about the measures implemented in the COVID-19 stetting was sufficient. 98.1% considered that the instructions about personal protective equipment were satisfactory, but 38% reported difficulties to use them. 92.5% of the residents agreed with the system implemented for on-call shifts, 94.5% increased the time dedicated to academic activities, 75% considered the virtual class schedule implemented as very useful and 72.72% perceived that they had spaces to express their concerns. The supervision was considered adequate by 60%; 81.81% were worried to lose manual dexterity; 53% felt frustrated and 54% were afraid of infecting their family/partner. Conclusion: Understanding the perceptions of surgeons in training in the initial phase of the COVID-19 pandemic made it possible to detect opportunities for improvement and incorporate modifications to address the following phases, ensuring learning and prioritizing their physical and psychosocial well-being.

Rol actual de la adrenalectomía bilateral en el manejo del síndrome de cushing ectópico / Current role of bilateral adrenalectomy in the management of ectopic Cushing's syndrome

Objetivo: Describir las característicasclínicas y los resultados perioperatorios de la adrenalectomía bilateral laparoscópica (ABL) en 5 pacientestratados con diagnóstico de Síndrome de Cushing Ectópico (SCE).Material y método: Se realizó un estudio retrospectivo y descriptivo de todos los pacientes con SCEsometidos a una ABL, entre enero de 2009 y junio de2017. Todos los pacientes fueron evaluados por unequipo multidisciplinario que decidió conjuntamente elmomento más adecuado para la cirugía. Fueron analizados los siguientes datos protocolares: edad, sexo, origen del tumor secretor, duración del hipercortisolismo,motivo de internación, manejo terapéutico inicial, datosbioquímicos (cortisol sérico preoperatorio, ACTH plasmática y cortisol libre urinario), datos quirúrgicos (vía deabordaje, tiempo quirúrgico, tipo de cirugía, necesidadde conversión a cirugía abierta), datos perioperatorios (tiempo de internación postoperatoria, complicacionessegún la escala de Clavien-Dindo, mortalidad, tasa decuración clínica y tasa de curación bioquímica, tiempode seguimiento).Resultados: Cinco pacientes fueron sometidos a ABL.El abordaje fue mínimamente invasivo, ya sea transperitoneal (n=3) o retroperitoneoscópico posterior (n=2). Eltiempo de internación fue de 23,4 días (r=4-81). Ningún paciente falleció por complicaciones quirúrgicas, ytodos lograron la curación bioquímica y clínica de suhipercortisolismo después de la cirugía.Conclusiones: ABL es un procedimiento de rescateeficaz para controlar los síntomas asociados al hipercortisolismo en pacientes con SCE refractario al tratamiento médico.(AU)

Objectives: The aim of this paper is todescribe the clinical features and the perioperative results of the bilateral laparoscopic adrenalectomy (BLA) ofsalvaje in 5 patients treated for an Ectopic Cushing Syndrome (CS) who were refractory to medical treatment.Material and methods: We performed a retrospective analysis of the clinical records of our institution.Five BLAs were performed in patients with Ectopic CSrefractory to medical treatment during the period fromJanuary 2009 and June 2017. All patients were evaluated by a multidisciplinary team that jointly decidedthe most appropriate time for surgery. The followingprotocol data were analyzed: age, sex, location of the secreting tumor, duration of hypercortisolism, reason forhospitalization, initial therapeutic management), biochemical data (pre-op serum cortisol, plasma ACTH andfree urinary cortisol), surgical data (surgical approach,surgical time, type of surgery, need for conversion toopen surgery), perioperative data (post op surgical stay,post op complications according to the Clavien-Dindoscale 14, mortality, clinical cure rate and biochemicalcure rate, follow up time).Results: Five patients underwent BLA. The approachfor the BLA was minimally invasive, either trans peritoneal (n=3) or posterior retroperitoneoscopic (n=2). Meanhospitalization time was 23.4 days (r=4-81). None ofthe patients died because of surgical complications, andall of them achieved biochemical and clinical remissionof their hypercortisolism after surgery.Conclusions: BLA is an effective salvage alternativeto control the symptoms associated with overproductionof corticosteroids in patients with ectopic CS refractoryto medical treatment.(AU)

[Current role of bilateral adrenalectomy in Ectopic Cushing syndrome.] / Rol actual de la adrenalectomía bilateral en el manejo del síndrome de Cushing Ectópico.

OBJECTIVES: The aim of this paper is to describe the clinical features and the perioperative results of the bilateral laparoscopic adrenalectomy (BLA) of salvaje in 5 patients treated for an Ectopic Cushing Syndrome (CS) who were refractory to medical treatment. MATERIALS AND METHODS: We performed a retrospective analysis of the clinical records of our institution. Five BLAs were performed in patients with Ectopic CS refractory to medical treatment during the period from January 2009 and June 2017. All patients were evaluated by a multidisciplinary team that jointly decided the most appropriate time for surgery. The following protocol data were analyzed: age, sex, location of the secreting tumor, duration of hypercortisolism, reason for hospitalization, initial therapeutic management), biochemical data (pre-op serum cortisol, plasma ACTH and free urinary cortisol), surgical data (surgical approach, surgical time, type of surgery, need for conversion toopen surgery), perioperative data (post op surgical stay, post op complications according to the Clavien-Dindo scale 14, mortality, clinical cure rate and biochemical cure rate, follow up time). RESULTS: Five patients underwent BLA. The approach for the BLA was minimally invasive, either trans peritoneal (n=3) or posterior retroperitoneoscopic (n=2). Mean hospitalization time was 23.4 days (r=4-81). None of the patients died because of surgical complications, and all of them achieved biochemical and clinical remission of their hypercortisolism after surgery. CONCLUSIONS: BLA is an effective salvage alter native to control the symptoms associated with overproduction of corticosteroids in patients with ectopic CS refractory to medical treatment.

OBJETIVO: Describir las características clínicas y los resultados perioperatorios de la adrenalectomía bilateral laparoscópica (ABL) en 5 pacientes tratados con diagnóstico de Síndrome de Cushing Ectópico (SCE).MATERIALES Y MÉTODOS: Se realizó un estudio retrospectivo y descriptivo de todos los pacientes con SCE sometidos a una ABL, entre enero de 2009 y junio de 2017. Todos los pacientes fueron evaluados por un equipo multidisciplinario que decidió conjuntamente el momento más adecuado para la cirugía. Fueron analizados los siguientes datos protocolares: edad, sexo, origen del tumor secretor, duración del hipercortisolismo, motivo de internación, manejo terapéutico inicial, datos bioquímicos (cortisol sérico preoperatorio, ACTH plasmática y cortisol libre urinario), datos quirúrgicos (vía de abordaje, tiempo quirúrgico, tipo de cirugía, necesidad de conversión a cirugía abierta), datos perioperatorios (tiempo de internación postoperatoria, complicaciones según la escala de Clavien-Dindo, mortalidad, tasa de curación clínica y tasa de curación bioquímica, tiempo de seguimiento). RESULTADOS: Cinco pacientes fueron sometidos a ABL. El abordaje fue mínimamente invasivo, ya sea transperitoneal (n=3) o retroperitoneoscópico posterior (n=2). El tiempo de internación fue de 23,4 días (r=4-81). Ningún paciente falleció por complicaciones quirúrgicas, y todos lograron la curación bioquímica y clínica de su hipercortisolismo después de la cirugía. CONCLUSIONES: ABL es un procedimiento de rescate eficaz para controlar los síntomas asociados al hipercortisolismo en pacientes con SCE refractario al tratamiento médico.

Laparoscopic Conversion of Gastric Plication to Roux-en-Y Gastric Bypass.

PURPOSE: Laparoscopic gastric plication (LGP) is a relative new bariatric procedure with a high revision rate, mostly to sleeve gastrectomy. There are few reported cases of conversion to Roux-en-Y gastric bypass (RYGB). The purpose of this video was to show the feasibility and safety, as well as the main technical aspects, of a laparoscopic conversion of gastric plication to RYGB. MATERIALS AND METHODS: A 40-year-old morbidly obese woman with a previous LGP, consulted for insufficient weight loss, weight regain, and gastroesophageal reflux disease (GERD) symptoms, and was converted to RYGB. RESULTS: Surgical technique included lysis of adhesions between the stomach and the greater omentum, take down of the plication, partial gastrectomy of the devascularized fundus and body and conversion to RYGB. At 30 months, she has achieved a total weight loss (TWL) of 42.43% with no GERD symptoms recurrence. CONCLUSION: Conversion to RYGB is a safe and effective option to treat weight recidivism and GERD after LGP.

Laparoscopic transcystic common bile duct exploration as treatment for choledocholithiasis after Roux-en-Y gastric bypass.

BACKGROUND: Treatment of choledocholithiasis after Roux-en-Y gastric bypass (RYGB) is a therapeutic challenge given the altered anatomy. To overcome this technical difficulty, different modified endoscopic approaches have been described but significant morbidity accompanies these procedures. The aim of the present study is to report our experience with laparoscopic transcystic common bile duct exploration (LTCBDE) as treatment of choledocholithiasis after RYGB. METHODS: This is a retrospective cohort study of 854 consecutive patients with RYGB at a single institution between January 2007 and December 2019. Our study population focused on patients who developed biliary events after RYGB. Demographic data and perioperative parameters were compared between patients who underwent laparoscopic cholecystectomy (LC) after RYGB with (defined as Group A) and without (defined as Group B) LTCBDE. RESULTS: Fifty-seven (8.93%) patients developed a biliary event after RYGB that led to LC. Of those, 11 (19.2%) presented choledocholithiasis during intraoperative cholangiogram and were simultaneously treated with LTCBDE (Group A). Choledocholithiasis was unsuspected in the preoperative setting in 7 (63.6%) of the 11 patients. The procedure was successful in 90.9% (n = 10). Comparing Group A and B, no statistically significant differences were found regarding age, gender, length of hospital stay, and morbidity (p > 0.05). Mean operative time of Group A was 113.1 min, adding, on average, 35 min to LC (113.1 min vs 77.9 min, p = 0.004). CONCLUSIONS: LTCBDE offers an effective approach for common bile duct stones in patients who underwent RYGB. This procedure did not add significant length of hospital stay nor morbidity to laparoscopic cholecystectomy.

Hematoma de la funduplicatura de Nissen / Hematoma of a Nissen fundoplication

No disponible

Effect of Roux-en-Y Gastric Bypass on Lipoprotein Metabolism and Markers of HDL Functionality in Morbid Obese Patients.

PURPOSE: Morbid obesity represents the most severe form of obesity and surgical intervention would be its only successful treatment. Bariatric surgery could generate modifications in carbohydrate metabolism and in lipid profile plus lipoprotein-associated proteins and enzymes, such as lipoprotein-associated phoslipase A2 (Lp-PLA2), cholesteryl ester transfer protein (CETP), and paraoxonase (PON) 1. The aim of the present study was to analyze changes in inflammation markers, carbohydrate metabolism, and lipid parameters in patients who underwent bariatric surgery. METHODS: Thirty-seven patients with morbid obesity were recruited. Evaluations were performed before (T0) and 1 (T1) and 6 (T2) months after surgery. Glucose, insulin, high-sensitivity C-reactive protein (hsCRP), triglycerides, total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol, apolipoproteins (apo) A-I, and B plus Interleukin 1ß and 6 levels in addition to CETP, Lp-PLA2, and PON 1 activities were determined. RESULTS: Body mass index decreased at T1 and T2 (p < 0.01). An improvement in all markers of insulin resistance (p < 0.05) was observed at T1. hsCRP levels diminished at T2 (p < 0.05). Triglyceride levels decreased at T1 and T2 (p < 0.05). HDL-C and apo A-I showed a decrease at T1 which was completely reversed at T2 (p < 0.05). Lp-PLA2 activity increased at T1, which was reversed at T2 (p < 0.05), and CETP activity was diminished at T2 (p < 0.05). PON and ARE activities decreased at T1 and partially recovered at T2 (p < 0.05). CONCLUSIONS: These results would be indicative of a favorable effect of bariatric surgery on markers of carbohydrate metabolism and cardiovascular disease lipid risk factors.

CoViD-19 Pandemic and Bariatric Surgery in Argentina.

Argentina was able to anticipate public health interventions in order to flatten the contagion curve of CoViD-19. Eighty-three surgeons answered an online survey to assess the impact of the pandemic on bariatric surgery (BS) in Argentina. Most of them showed a high economic dependence on BS. Near 90% of health institutions were on phase 0 or I. While 90% still performed other laparoscopic surgeries, BS was suspended. In many surgeries for nonsuspected CoViD-19 patients, high personnel protection resources were applied. Ninety-five percent offered virtual consults. Most surgeons would not change usual algorithms or techniques. To restart BS a scientific society recommendation was expected, including patient selection criteria. The opinions gathered by this survey were taken into account to elaborate official recommendations for restarting elective BS.

Laparoscopic Removal of Eroded Non-Adjustable Gastric Band and Conversion to Roux-en-Y Gastric Bypass.

This video shows the case of a 64-year-old morbidly obese woman, with a non-adjustable gastric band, who consulted for weight regain and gastroesophageal reflux disease (GERD) symptoms and was converted to Roux-en-Y gastric bypass (RYGB). The operative technique included extensive lysis of adhesions, complete band dissection, partial gastrectomy of the fundus and body due to band erosion and conversion to RYGB.