Textbook outcome in patients with biliary duct injury during cholecystectomy.

BACKGROUND: Iatrogenic bile duct injury (BDI) during cholecystectomy is associated with a complex and heterogeneous management owing to the burden of morbidity until their definitive treatment. This study aimed to define the textbook outcomes (TOs) after BDI with the purpose to indicate the ideal treatment and to improve it management. METHODS: We collected data from patients with an BDI between 1990 and 2022 from 27 hospitals. TO was defined as a successful conservative treatment of the iatrogenic BDI or only minor complications after BDI or patients in whom the first repair resolves the iatrogenic BDI without complications or with minor complications. RESULTS: We included 808 patients and a total of 394 patients (46.9%) achieved TO. Overall complications in TO and non-TO groups were 11.9% and 86%, respectively (P < .001). Major complications and mortality in the non-TO group were 57.4% and 9.2%, respectively. The use of end-to-end bile duct anastomosis repair was higher in the non-TO group (23.1 vs 7.8, P < .001). Factors associated with achieving a TO were injury in a specialized center (adjusted odds ratio [aOR], 4.01; 95% CI, 2.68-5.99; P < .001), transfer for a first repair (aOR, 5.72; 95% CI, 3.51-9.34; P < .001), conservative management (aOR, 5.00; 95% CI, 1.63-15.36; P = .005), or surgical management (aOR, 2.45; 95% CI, 1.50-4.00; P < .001). CONCLUSION: TO largely depends on where the BDI is managed and the type of injury. It allows hepatobiliary centers to identify domains of improvement of perioperative management of patients with BDI.

Solid pseudopapillary neoplasms of the pancreas: Multicenter Vasepa study.

INTRODUCTION: Solid pseudopapillary tumors (SPT) of the pancreas are rare exocrine neoplasms of the pancreas. Correct preoperative diagnosis is not always feasible. The treatment of choice is surgical excision. These tumors have a good prognosis with a high disease-free survival rate. OBJECTIVE: To describe the clinicopathological and radiological characteristics as well as short- and long-term follow-up results of patients who have undergone SPT resection. METHODS: Multicenter retrospective observational study in patients with SPT who had undergone surgery from January 2000-January 2022. We have studied preoperative, intraoperative, and postoperative variables as well as the follow-up results (mean 28 months). RESULTS: 20 patients with histological diagnosis of SPT in the surgical specimen were included. 90% were women; mean age was 33.5 years (13-67); 50% were asymptomatic. CT was the most used diagnostic test (90%). The most frequent location was body-tail (60%). Preoperative biopsy was performed in 13 patients (65%), which was correct in 8 patients. Surgeries performed: 7 distal pancreatectomies, 6 pancreaticoduodenectomies, 4 central pancreatectomies, 2 enucleations, and 1 total pancreatectomy. The R0 rate was 95%. Four patients presented major postoperative complications (Clavien-Dindo > II). Mean tumor size was 81 mm. Only one patient received adjuvant chemotherapy. With a mean follow-up of 28 months, 5-year disease-free survival was 95%. CONCLUSION: SPT are large, usually located in the body-tail of the pancreas, and more frequent in women. The R0 rate obtained in our series is very high (95%). The oncological results are excellent.

Neoadjuvant Chemotherapy plus Interval Cytoreductive Surgery with or without Hyperthermic Intraperitoneal Chemotherapy (NIHIPEC) in the Treatment of Advanced Ovarian Cancer: A Multicentric Propensity Score Study.

INTRODUCTION: Epithelial ovarian cancer (EOC) is primarily confined to the peritoneal cavity. When primary complete surgery is not possible, neoadjuvant chemotherapy (NACT) is provided; however, the peritoneum-plasma barrier hinders the drug effect. The intraperitoneal administration of chemotherapy could eliminate residual microscopic peritoneal tumor cells and increase this effect by hyperthermia. Intraperitoneal hyperthermic chemotherapy (HIPEC) after interval cytoreductive surgery could improve outcomes in terms of disease-free survival (DFS) and overall survival (OS). MATERIALS AND METHODS: A multicenter, retrospective observational study of advanced EOC patients who underwent interval cytoreductive surgery alone (CRSnoH) or interval cytoreductive surgery plus HIPEC (CRSH) was carried out in Spain between 07/2012 and 12/2021. A total of 515 patients were selected. Progression-free survival (PFS) and OS analyses were performed. The series of patients who underwent CRSH or CRSnoH was balanced regarding the risk factors using a statistical analysis technique called propensity score matching. RESULTS: A total of 170 patients were included in each subgroup. The complete surgery rate was similar in both groups (79.4% vs. 84.7%). The median PFS times were 16 and 13 months in the CRSH and CRSnoH groups, respectively (Hazard ratio (HR) 0.74; 95% CI, 0.58-0.94; p = 0.031). The median OS times were 56 and 50 months in the CRSH and CRSnoH groups, respectively (HR, 0.88; 95% CI, 0.64-1.20; p = 0.44). There was no increase in complications in the CRSH group. CONCLUSION: The addition of HIPEC after interval cytoreductive surgery is safe and increases DFS in advanced EOC patients.

Vascular injury during cholecystectomy: A multicenter critical analysis behind the drama.

BACKGROUND: The management of a vascular injury during cholecystectomy is still very complicated, especially in centers not specialized in complex hepatobiliary surgery. METHODS: This was a multi-institutional retrospective study in patients with vascular injuries during cholecystectomy from 18 centers in 4 countries. The aim of the study was to analyze the management of vascular injuries focusing on referral, time to perform the repair, and different treatments options outcomes. RESULTS: A total of 104 patients were included. Twenty-nine patients underwent vascular repair (27.9%), 13 (12.5%) liver resection, and 1 liver transplant as a first treatment. Eighty-four (80.4%) vascular and biliary injuries occurred in nonspecialized centers and 45 (53.6%) were immediately transferred. Intraoperative diagnosed injuries were rare in referred patients (18% vs 84%, P = .001). The patients managed at the hospital where the injury occurred had a higher number of reoperations (64% vs 20%, P ˂ .001). The need for vascular reconstruction was associated with higher mortality (P = .04). Two of the 4 patients transplanted died. CONCLUSION: Vascular lesions during cholecystectomy are a potentially life-threatening complication. Management of referral to specialized centers to perform multiple complex multidisciplinary procedures should be mandatory. Late vascular repair has not shown to be associated with worse results.

Machine Learning-Based Analysis in the Management of Iatrogenic Bile Duct Injury During Cholecystectomy: a Nationwide Multicenter Study.

BACKGROUND: Iatrogenic bile duct injury (IBDI) is a challenging surgical complication. IBDI management can be guided by artificial intelligence models. Our study identified the factors associated with successful initial repair of IBDI and predicted the success of definitive repair based on patient risk levels. METHODS: This is a retrospective multi-institution cohort of patients with IBDI after cholecystectomy conducted between 1990 and 2020. We implemented a decision tree analysis to determine the factors that contribute to successful initial repair and developed a risk-scoring model based on the Comprehensive Complication Index. RESULTS: We analyzed 748 patients across 22 hospitals. Our decision tree model was 82.8% accurate in predicting the success of the initial repair. Non-type E (p < 0.01), treatment in specialized centers (p < 0.01), and surgical repair (p < 0.001) were associated with better prognosis. The risk-scoring model was 82.3% (79.0-85.3%, 95% confidence interval [CI]) and 71.7% (63.8-78.7%, 95% CI) accurate in predicting success in the development and validation cohorts, respectively. Surgical repair, successful initial repair, and repair between 2 and 6 weeks were associated with better outcomes. DISCUSSION: Machine learning algorithms for IBDI are a novel tool may help to improve the decision-making process and guide management of these patients.

GECOP-MMC: phase IV randomized clinical trial to evaluate the efficacy of hyperthermic intraperitoneal chemotherapy (HIPEC) with mytomicin-C after complete surgical cytoreduction in patients with colon cancer peritoneal metastases.

BACKGROUND: The French PRODIGE 7 trial, published on January 2021, has raised doubts about the specific survival benefit provided by HIPEC with oxaliplatin 460 mg/m2 (30 minutes) for the treatment of peritoneal metastases from colorectal cancer. However, several methodological flaws have been identified in PRODIGE 7, specially the HIPEC protocol or the choice of overall survival as the main endpoint, so its results have not been assumed as definitive, emphasizing the need for further research on HIPEC. It seems that the HIPEC protocol with high-dose mytomicin-C (35 mg/m2) is the preferred regime to evaluate in future clinical studies. METHODS: GECOP-MMC is a prospective, open-label, randomized, multicenter phase IV clinical trial that aims to evaluate the effectiveness of HIPEC with high-dose mytomicin-C in preventing the development of peritoneal recurrence in patients with limited peritoneal metastasis from colon cancer (not rectal), after complete surgical cytoreduction. This study will be performed in 31 Spanish HIPEC centres, starting in March 2022. Additional international recruiting centres are under consideration. Two hundred sixteen patients with PCI ≤ 20, in which complete cytoreduction (CCS 0) has been obtained, will be randomized intraoperatively to arm 1 (with HIPEC) or arm 2 (without HIPEC). We will stratified randomization by surgical PCI (1-10; 11-15; 16-20). Patients in both arms will be treated with personalized systemic chemotherapy. Primary endpoint is peritoneal recurrence-free survival at 3 years. An ancillary study will evaluate the correlation between surgical and pathological PCI, comparing their respective prognostic values. DISCUSSION: HIPEC with high-dose mytomicin-C, in patients with limited (PCI ≤ 20) and completely resected (CCS 0) peritoneal metastases, is assumed to reduce the expected risk of peritoneal recurrence from 50 to 30% at 3 years. TRIAL REGISTRATION: EudraCT number: 2019-004679-37; Clinicaltrials.gov: NCT05250648 (registration date 02/22/2022, ).

Effect of Preoperative Immunonutrition on Postoperative Major Morbidity after Cytoreductive Surgery and HIPEC in Patients with Peritoneal Metastasis.

The effect of preoperative immunonutrition intake on postoperative major complications in patients following cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) was assessed. The accuracy of C-Reactive Protein (CRP) for detecting postoperative complications was also analyzed. Patients treated within a peritoneal carcinomatosis program in which a complete or optimal cytoreduction was achieved were retrospectively analyzed. They were divided into two groups based on whether preoperative immunonutrition (IMN) or not (non-IMN) were administered. Clinical and surgical variables and postoperative complications were gathered. Predictive values of major morbidity of CRP during the first 3 postoperative days (POD) were also evaluated. A total of 107 patients were included, 48 belonging to the IMN group and 59 to the non-IMN group. In multivariate analysis immunonutrition (OR 0.247; 95%CI 0.071-0.859; p = 0.028), and the number of visceral resections (OR 1.947; 95%CI 1.086-3.488; p = 0.025) emerged as independent factors associated with postoperative major morbidity. CRP values above 103 mg/L yielded a negative predictive value of 84%. Preoperative intake of immunonutrition was associated with a decrease of postoperative major morbidity and might be recommended to patients with peritoneal carcinomatosis following CRS. Measuring CRP levels during the 3 first postoperative days is useful to rule out major morbidity.

Hair loss in females after sleeve gastrectomy: predictive value of serum zinc and iron levels.

A common complication after bariatric surgery is hair loss, which is related to rapid weight reduction, but zinc, iron, and other micronutrient deficiencies can also be involved. Little is studied after laparoscopic sleeve gastrectomy (LSG). A prospective observational study was performed of 42 morbidly obese females undergoing LSG. Incidence of hair loss was monitored. Micronutrients were investigated preoperatively and three, six, and 12 months after surgery. Sixteen patients (41%) reported hair loss in the postoperative course. A significant association was observed between hair loss and zinc levels (P = 0.021) but mean zinc levels were within the normal range in patients reporting hair loss. Only three patients (7.7%) presented low zinc levels, all of them reporting hair loss. There was also a significant association between iron levels and alopecia (P = 0.017), but mean values of the patients with hair loss were within normal range. Only four patients (10.2%) presented low iron levels, all of them presenting hair loss. A variable consisting of the addition of zinc + iron showed a significant association with hair loss (P = 0.013). A cutoff point was established in 115 (odds ratio, 4; P = 0.006). All the patients but two reporting hair loss presented addition levels under 115. This variable showed sensibility 88 per cent, specificity 84 per cent, positive predictive value 79 per cent, and negative predictive value 91 per cent to predict hair loss. Hair loss is a frequent condition after sleeve gastrectomy. In most cases, iron and zinc levels are within the normal range. The variable addition (zinc + iron) is a good predictor of hair loss. Patients with addition levels below 115 are fourfold more susceptible to present hair loss. In these cases, zinc supplements achieve the stop of hair loss in most cases.

Pre-operative and early post-operative factors associated with surgical site infection after laparoscopic sleeve gastrectomy.

BACKGROUND: Surgical procedures on obese patients are expected to have a high incidence of surgical site infection (SSI). The identification of pre-operative or early post-operative risk factors for SSI may help the surgeon to identify subjects in risk and adequately optimize their status. We conducted a study of the association of comorbidities and pre- and post-operative analytical variables with SSI following laparoscopic sleeve gastrectomy for the treatment of morbid obesity. PATIENTS AND METHODS: We performed a prospective study of all morbidly obese patients undergoing laparoscopic sleeve gastrectomy as a bariatric procedure between 2007 and 2011. An association of clinical and analytical variables with SSI was investigated. RESULTS: The study included 40 patients with a mean pre-operative body mass index (BMI) of 51.2±7.9 kg/m(2). Surgical site infections appeared in three patients (7.5%), of whom two had an intra-abdominal abscess located in the left hypochondrium and the third had a superficial incisional SSI. Pre-operatively, a BMI >45 kg/m(2) (OR 8.7; p=0.008), restrictive disorders identified by pulmonary function tests (OR 10.0; p=0.012), a serum total protein concentration <5.3 g/dL (OR 13; p=0.003), a plasma cortisol >30 mcg/dL (OR 13.0; p=0.003), and a mean corpuscular volume (MCV) <82 fL (OR 1.6; p=0.04) were associated with post-operative SSI. Post-operatively, a serum glucose >128 mg/dL (OR 4.7; p=0.012) and hemoglobin <11g/dL (OR 7.5; p=0.002) were associated with SSI. CONCLUSIONS: The study supports the role of restrictive lung disorders and the values specified above for preoperative BMI, serum total protein and cortisol concentrations, and MCV, and of post-operative anemia and hyperglycemia as risk factors for SSI. In these situations, the surgeon must be aware of and seek to control these risk factors.

Short- and mid-term changes in bone mineral density after laparoscopic sleeve gastrectomy.

BACKGROUND: Bariatric surgery is the most effective treatment for achieving a significant weight loss. Morbidities present a significant reduction after bariatric surgery, but it may also result in several health complications, related to nutritional deficiencies, including bone metabolism. Several studies have reported a decrease in bone mineral density (BMD), but most of them referring to malabsorptive procedures. Restrictive procedures do not imply changes in gastrointestinal anatomy, so that one may expect fewer metabolic disturbances. METHODS: We performed a retrospective observational study of all morbidly obese patients undergoing LSG between 2008 and 2011 at our institution. Bone densitometry was performed before surgery and 1 and 2 years after the intervention. Body size measurements, analytical variables and densitometric values in the lumbar spine (BMD, t score and z score) were investigated. RESULTS: Forty-two patients were included, 39 females and 3 males. Mean BMI was 51.21 kg/m(2). Mean excessive BMI loss was 79.9 % after 1 year and 80.6 % after 2 years. Mean BMD values for spine increased progressively, reaching statistical significance at 1 and at 2 years. Percentage of BMD increase was 5.7 % at 1 year and 7.9 % at 2 years. An inverse correlation was observed between BMD increase and parathyroid hormone (PTH) decrease and a direct correlation between BMD and vitamin D increase. CONCLUSION: Bone mineral density showed a progressive increase during the first and second year after sleeve gastrectomy. BMD changes are not associated with weight loss, but showed a direct correlation with vitamin D and an inverse correlation with PTH levels.

Change in levels of C-reactive protein (CRP) and serum cortisol in morbidly obese patients after laparoscopic sleeve gastrectomy.

BACKGROUND: C-Reactive protein (CRP) has been associated with the macro- and microvascular effects of hypertension and diabetes mellitus. Referring to serum cortisol, it has been proposed to contribute to the pathogenesis of metabolic syndrome, and it has been demonstrated that weight loss normalizes cortisol levels and improves insulin resistance. The aims of this study were to analyze CRP and cortisol levels pre- and postoperatively in morbidly obese patients undergoing a laparoscopic sleeve gastrectomy and to correlate them with weight loss and parameters associated with cardiovascular risk. METHODS: A prospective study of all the morbidly obese patients undergoing laparoscopic sleeve gastrectomy as bariatric procedure between October 2007 and May 2011 was performed. RESULTS: A total of 40 patients were included in the study. CRP levels decreased significantly 12 months after surgery (median reduction of 8.9 mg/l; p = 0.001). Serum cortisol levels decreased significantly 6 months after surgery (median reduction of 34.9 µg/dl; p = 0.001). CRP values reached the normal range (<5 mg/l) 1 year after surgery. Referring to cortisol, a significant association was observed with the cardiovascular risk predictor (triglyceride/high-density lipoprotein cholesterol ratio) from the 6th month after surgery onward (Pearson correlation coefficient, 0.559; p = 0.008). CONCLUSION: CRP levels are increased preoperatively and in the postoperative course up to 1 year after surgery. Serum cortisol levels remain elevated until the 6th month after surgery. From this moment onward, serum cortisol is associated with the cardiovascular risk predictor reflecting the cardiovascular risk decreasement during the weight loss.

Midterm impact of sleeve gastrectomy, calibrated with a 50-Fr bougie, on weight loss, glucose homeostasis, lipid profiles, and comorbidities in morbidly obese patients.

Bariatric surgery has been shown to be effective in achieving and maintaining weight change and reducing obesity-related comorbidities. Recent reports have shown that sleeve gastrectomy could have similar resolution rates of the metabolic syndrome than Roux-Y bypass after a short-term follow-up of 1 year. Most surgeons calibrate the sleeve with 32-Fr to 40-Fr bougies. There is little mid- and long-term information available about the evolution of these comorbidities with this procedure and with calibration of the sleeve with a 50-Fr bougie. A retrospective study of all the morbidly obese patients undergoing laparoscopic sleeve gastrectomy, calibrated with a 50-Fr bougie, as bariatric procedure between October 2007 and September 2009 was performed. Mean excessive body mass index loss was 76.9 per cent after 1 year and 79.9 per cent after 2 years. After surgery, 83.3 per cent of patients with Type 2 diabetes mellitus discontinued their hypoglycemic medication at 1 month. All the patients with hypertension discontinued antihypertensive drugs at 6 months. One hundred per cent of patients with hypertriglyceridemia discontinued their hypolipidemic drugs at 3 months. Glucose levels decreased significantly 3 months after surgery (mean reduction of 24.7 mg/dL; 95% confidence interval [CI], 8.8 to 40.7; P = 0.003). Triglyceride levels decreased 3 months after surgery (mean reduction of 54.4 mg/dL; 95% CI, 22.8 to 86.1; P = 0.004). High-density lipoprotein (HDL) cholesterol increased significantly after 12 months (increase of 16.7 mg/dL; 95% CI, 11.7 to 21.7; P < 0.001). The changes observed were maintained 24 months after surgery. Sleeve gastrectomy, calibrated with a 50-Fr bougie, significantly reduced glucose and triglyceride levels and the cardiovascular risk predictor triglyceride/HDL ratio and increased HDL levels after surgery and maintained them under normal ranges for at least 2 years.

¿Existe alguna indicación de colocación de drenaje en la colecistectomía laparoscópica electiva? / Is there any indication for inserting a drain in elective laparoscopic cholecystectomy?

Introducción Clásicamente, se colocaba un drenaje subhepático de forma sistemática en la colecistectomía para prevenir los abscesos intraabdominales, posibles sangrados postoperatorios y fístulas biliares. Con el tiempo se ha ido demostrando que el uso sistemático de drenaje no aporta beneficios, pero muchos estudios concluyen que, en circunstancias especiales (sangrado, signos inflamatorios en la vesícula biliar, apertura incidental o sospecha de fuga biliar) y según la experiencia de cada cirujano, la indicación de colocación de un drenaje puede tener cabida. Material y métodos Realizamos un estudio prospectivo de 100 colecistectomías laparoscópicas consecutivas, intervenidas de forma electiva por colelitiasis sintomática o pólipos vesiculares. En 15 de ellas se colocó un drenaje subhepático. Las indicaciones para colocarlo fueron: en 11 pacientes como «testigo» por sangrado del lecho vesicular controlado intraoperatoriamente y en 4 por apertura de la vesícula con salida de bilis de aspecto turbio-purulento. Las variables principales investigadas fueron la utilidad clínica que ha tenido la colocación del drenaje, la estancia hospitalaria y la cuantificación del dolor a las 24h de la intervención por parte del paciente mediante una escala analógico-visual. Resultados En ningún paciente la colocación del drenaje tuvo utilidad alguna. La mediana de estancia hospitalaria aumentó un día en los pacientes con drenaje (p=0,002). La mediana de dolor a las 24h de la intervención en los pacientes con drenaje fue mayor (p=0,018).Conclusión La colocación de un drenaje subhepático tras colecistectomía laparoscópica programada aumenta el dolor postoperatorio y prolonga la estancia hospitalaria, pero no previene la aparición de abscesos intraabdominales (AU)

Introduction Classically, a sub-hepatic drain was inserted routinely in a cholecystectomy to prevent intra-abdominal abscesses, possible post-surgical bleeding, and biliary fistulas. Over the years, it has been demonstrated that the systematic use of a drain does not have any benefits, and many studies conclude that, in special circumstances (bleeding, signs of gallbladder inflammation, incidental opening, or suspected bile leak), and depending on the experience of the individual surgeon, the insertion of a drain may be of use. Material y methods A prospective study was conducted on 100 elective laparoscopic cholecystectomies performed due to symptomatic cholelithiasis or gallbladder polyps. A sub-hepatic drain was inserted in 15 of them. The indications for inserting it were: in 11 patients as a "control" due to a gallbladder bed bleed controlled during surgery, and in 4 due to a gallbladder opening with the excretion of turbid-purulent bile. The main outcomes investigated were the clinical benefit achieved by the insertion of the drain, the hospital stay, and the quantifying of the pain by the patients 24h after surgery, using a visual analogue scale. Results The insertion of a drain was of no benefit to any patient. The median hospital stay increased by 1 day in patients with a drain (P=.002). The median pain score at 24h was higher in patients with a drain inserted (P=.018).Conclusion The insertion of a sub-hepatic drain after elective laparoscopic cholecystectomy increases post-surgical pain and prolongs hospital stay, and does not prevent the occurrence of intra-abdominal abscesses (AU)

[Is there any indication for inserting a drain in elective laparoscopic cholecystectomy?]. / ¿Existe alguna indicación de colocación de drenaje en la colecistectomía laparoscópica electiva?

INTRODUCTION: Classically, a sub-hepatic drain was inserted routinely in a cholecystectomy to prevent intra-abdominal abscesses, possible post-surgical bleeding, and biliary fistulas. Over the years, it has been demonstrated that the systematic use of a drain does not have any benefits, and many studies conclude that, in special circumstances (bleeding, signs of gallbladder inflammation, incidental opening, or suspected bile leak), and depending on the experience of the individual surgeon, the insertion of a drain may be of use. MATERIAL AND METHODS: [corrected] A prospective study was conducted on 100 elective laparoscopic cholecystectomies performed due to symptomatic cholelithiasis or gallbladder polyps. A sub-hepatic drain was inserted in 15 of them. The indications for inserting it were: in 11 patients as a "control" due to a gallbladder bed bleed controlled during surgery, and in 4 due to a gallbladder opening with the excretion of turbid-purulent bile. The main outcomes investigated were the clinical benefit achieved by the insertion of the drain, the hospital stay, and the quantifying of the pain by the patients 24h after surgery, using a visual analogue scale. RESULTS: The insertion of a drain was of no benefit to any patient. The median hospital stay increased by 1 day in patients with a drain (P=.002). The median pain score at 24h was higher in patients with a drain inserted (P=.018). CONCLUSION: The insertion of a sub-hepatic drain after elective laparoscopic cholecystectomy increases post-surgical pain and prolongs hospital stay, and does not prevent the occurrence of intra-abdominal abscesses.

Mid-term effects of sleeve gastrectomy on calcium metabolism parameters, vitamin D and parathormone (PTH) in morbid obese women.

BACKGROUND: Despite routine supplementation of vitamins and minerals after bariatric surgery, an important number of patients suffer from deficiencies. Little is still known about the novel restrictive procedure, sleeve gastrectomy. METHODS: A retrospective study of 30 morbidly obese patients undergoing a laparoscopic sleeve gastrectomy, between May 2008 and September 2010, was performed. Baseline albumin, ferritin, iron, zinc, calcium, vitamin D, parathormone (PTH), vitamin B12, and folic acid were obtained before operation and postoperative determinations 1, 3, 6, 9, 12, 18, and 24 months after surgery. RESULTS: Before surgery, 96.7% of the patients presented vitamin D deficiency, 20% had elevated PTH, 3.3% hypoalbuminemia, and 3.3% folic acid deficiency. One year after surgery, only one patient (3.3%) presented vitamin D deficiency and had elevated PTH. The rest of parameters were within normal range. The second year after surgery, the results remain similar. A significant difference was obtained when comparing preoperative vitamin D values and postoperative determinations 12 months after surgery (increase of 51.9 ng/dl, 95% confidence interval (CI) (41.8-61.3); p < 0.001). A significant difference was determined when comparing preoperative PTH values and postoperative determinations 3 months after surgery (decrease of 16.6 pg/ml, 95% CI (2.6-30.6); p = 0.03). A significant inverse correlation was observed between weight loss and vitamin D increase at the third month after surgery (Pearson correlation coefficient -0.948; p = 0.033). CONCLUSIONS: Postoperative values of vitamin D show a progressive increase, while PTH ones present a significant reduction, without any impact on serum calcium levels. We have demonstrated an inverse correlation between weight loss and vitamin D increase at the third month after surgery.

Ultrashort bowel syndrome: surgical management and long-term results of an exceptional case.

Management of the short bowel syndrome is a multidisciplinary and very complex problem. The authors report the successful long-term results of an original combination of autologous gastrointestinal reconstruction in a boy who at the age of 16 years lost all but 5 cm of the small bowel. This case demonstrates that lengthening and antipropulsive interposition of a long segment of the colon can be another alternative to early transplantation in exceptional cases.